ONLINE PHYSICIAN REFERRAL

If you are a Health care Provider, you can submit the form below in the place of a referral. Be sure to FAX us the remaining health documents such as: pertinent medication lists, past medical history and other reports like ECG, cardiac consultations and previous colonoscopy and gastroscopy reports. 

Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

Please select the requested service(s):

Thanks for submitting!