Referral Request Form

This form will allow you to submit a request for referral online. Once you have completed the form and click on the submit button you will receive a confirmation of your submission. All referral requests are handled by our referral coordinator. Routine referrals are obtained every Friday. We ask that you request referrals a minimum of 1 week prior to the scheduled appointment. All urgent requsts should be requested by contacting our referral coordinator by calling the office (305) 448-8134 between 9:30 AM and 4:00 PM, Monday through Friday.

* Required fields
Name *
E-mail Address *
Name of your insurance company *
Referral Requested; Name of healthcare provider
Have you already scheduled the appointment with the individual you are requesting a referral to? *
If you have already scheduled the visit, please tell us the date of the appointment.
If you know the type of specialist you need a referral to but are unsure of the name of the doctor, please list the type of specialist here and we will help you find one
If there is any additional information you think we should know in order to assist you with your referral, let us know here

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