1. Referring Providers

    Thank you for entrusting us with the care of your patient. We strive to provide exceptional care and unparalleled customer service. Please contact us at 256-461-9654 if you need further assistance.

    Please fill out the required fields below so that we may contact your patient to schedule their evaluation.

  2. Physician's Name(*)
    Invalid Input
  3. Patient's Name(*)
    Invalid Input
  4. Patient's Phone(*)
    Invalid Input

  5. Alabama State law also requires a written prescription.

    Please scan and attach below.

  6. Prescription
    Invalid Input
  7. If you prefer, you may fax the patient's prescription to 256-461-9728.
    If you upload, note that it can take a few minutes to complete
    based upon your connection speed.