First Name
Last Name
Are you requesting consult to a hospital, your clinic, our clinic or a home visit for your patient?
Please fax the following to our office:
(1) Prescription
(2) Patient Face Sheet
(3) Most recent patient clinical note

FAX (214) 819-8047

Please complete information to the right with your information.
NOTE: Patients must have a current prescription with diagnosis from the referring Physician to be evaluated.