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, Angela Pena. 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 Angela by calling the office (305)448-8134 between 9:30 AM and 1:00 PM.

* 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

I have read and agree to the Privacy Policy *

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 (305) 448-8134

 Fax: (305) 445-2691
2645 SW 37 Ave Unit 502
Miami, Fl 33133

Doctor Miami Home Page / About the Doctor /Services Provided / Patient Requests / HouseCalls / Immigration Medical Exam /
Immigration Vaccines / Dermatology Miami / Identify Skin Cancer / Gynecology Miami / Pap Smears / Orthopedic Services / Travel Medicine / STD Testing & Treatment / Gonorrhea / Chlamydia / Herpes / HPV / HIV / Hepatitis B / Syphilis / Spider Veins / Ultrasound / Stop Smoking / Uninsured Patients / On-Site Pharmacy / Recommend Our Practice / Hours / FAQ's / Location Map / Resources and Links / Insurance Plans / Contact Us / Appointment Request / Patient Request  / Employment Opportinities / Patient Satisfaction Survey / MDVIT Herpes Vitamin