702-796-8500
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Refer a Patient
Refer a Patient
Schedule an Appointment:
702-796-8500
6410 Medical Center St Ste A, Las Vegas, NV 89148
To refer a patient to us, please call (702) 796-8500, or fax your referral form to (702) 796-8502. For your convenience, you may also submit the form below.
Patient Information
Patient Name
DOB
Home Phone
Mobile Phone
Primary Insurance
Primary Insurance Phone
Secondary Insurance
Secondary Insurance Phone
Diagnosis
Symptoms
Referring Physician Information
Physician Name
Specialty
Physician Phone
Physician Fax
Service Requested
Evaluation & Treatment
NCV/EMG
EEG
ENG
Evoked Potential
BAER
VEP
SSEP
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