Provider Referrals

We are accepting new patients! If you are a provider please complete the form below. We will reach out to the patient within 48 hours. We are scheduling new patients within 2 weeks. If you need your patient to be seen sooner, please call us at 864-520-4474.

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Patient Name

First Name

Last Name

Patient Date of Birth

YYYY

Patient Phone

(###)

###

####

Patient Email

Parent/ Guardian Name if Patient is under 18

First Name

Last Name

Referring Provider

First Name

Last Name

Provider/Office Phone

(###)

###

####

Reason for referral and any additional pertinent information.

Is the patient or responsible party aware that our office is self pay?

Yes