Submit a Referral

Requesting Party (Please fill out the form completely)

Attorney Firm Name

Point of Contact

State

Phone

Fax

Injured Party Information

First Name

Last Name

Date of Accident

Date of Birth

Phone

Cell Phone

Address

City

State

Zip Code

Requested Procedure Information

Treatment Request

Has your client received any medical treatment to date?

Diagnosis/Symptoms

Provider or Facility Requested

Phone

Fax

Upload the signed physician referral form here, or fax to: 702-202-2052

A physician script attachment is required because the treatment requested is Imaging.

Please upload the signed physician referral form here, or fax to: 702-463-4259