Referral form:

Provider's Name:		Phone:		email*:
Patient's Name:		Phone:		email*:		DOB:
Referral diagnosis:
Referral reason:	Pain: Acute Subacute Chronic	Rehab		Worker's Comp
Referral type:	Consult, recommendations and followup		Consult and recommendations only (no followup)
Additional comments:
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*Secure email will always be used for protected information.   Provider's email and phone need to be entered only once unless changed - we keep them on file.

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Upload files:
You can upload up to three files up to 1mb each of the following types: .txt, .xls, .doc, .rtf, .pdf, .fdf, .img, .jpg, .png, .tif
This can be used to send us files containing patient demographics, notes, etc.       Note: large files will take time to upload.

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Secure email:

Sender's Name:	email*:	Password for return email:
Subject:
Body:
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*Secure email will always be used for protected information.   Provider's email and password need to be entered only once unless changed - we keep them on file.

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Contact information:

	Office address:	1016 W University Ave, Flagstaff AZ 86001
	Mailing address:	PO Box 23364, Flagstaff Arizona 86002-3364
	Phone:	928-714-7090
	Fax:	928-220-8879
	Non secure email:

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Opioid Management CME References