Please complete and submit this form to refer cases to our specialty services.

You must hit the “submit” button at the bottom of the form to transmit the record.

Referral & Medical History Form

  • Please do not refer cases for emergency and critical care via our online form. Please call the clinic right away for these cases.

  • If no referral say Self-Referral
  • Date Format: MM slash DD slash YYYY
  • Drop files here or
      You can upload a maximum of 5 files. Uploads may not exceed 5MB each.
    • If you have problems uploading, please email to or fax to 651-501-3763.
    • This field is for validation purposes and should be left unchanged.