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Referring Healthcare Providers

If you are a healthcare provider and looking to refer a patient, please complete the online form here or call Dr. Tannoury's office. We will be in contact with you within 24 hours.

Healthcare Provider Information
Healthcare Provider Name*
Healthcare Provider Email*	Healthcare Provider Phone Number*

If the referring provider has any patient background documentation to share, please upload here. If you have multiple files to share, you will need to attach them using a single zip file. File Size: 5000KB Maximum

Please provide any information regarding your patient
First Name	Last Name
Phone Number
Email

Date of Injury (MM/DD/YY)	Date of Desired Visit

Purpose of Visit* First ConsultationSecond OpinionFollow Up VisitRequesting Information

Worker's Compensation YesNo

Insurance Name
In your own words, what you would like to achieve from this visit?

If you have any patient medical documentation to share, including x-rays, MRIs and CT scans, please upload them here. If you have multiple files to share, you will need to attach them using a single zip file. File Size: 5000KB Maximum
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Referring Healthcare Providers

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