The information requested above is Protected Health Information (PHI), and is the minimum necessary to execute delivery of patient services. Please understand as a link in the “Chain of Trust”, all PHI will remain confidential as mandated by the Treatment, Payments, and Healthcare Operation Laws mandated by HIPAA

Patient Referral Form

Please provide the following patient information and we will contact them for scheduling

1228 East 7th Ave.

Suite 200

Tampa, FL 33605

Phone: (813) 586-3848

Fax: (813) 491-8618 

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