Referring Doctors Thank you for trusting us to provide the best of care for your patients. We do our very best to accommodate your scheduling needs and that of your patients. If you have an emergency and would like for your patient to be seen STAT….Please call us directly at 719.473.9595 ext. 0 All other referrals please download the Fax Referral Form and fax to 719.227.0669 or Please fill out our online form: Please enable JavaScript in your browser to complete this form.Date *Patient Name *FirstLastDate of Birth *Patient's Home Phone *Patient's Work PhonePatient's Cell PhoneReason for consultation *How long has the patient had these symptoms? *When should we schedule your patient? *Within 2-3 daysWithin 7-10 daysNext available Preferred Office LocationColorado Springs OfficePueblo OfficeReferring Physician's Name *Physician location *Physician Phone Number *Physician Fax Number *Email address so we can send you a confirmationAdditional NotesNameSubmit
