Pure Health Medicine – Book Your Telemedicine Appointment
Phone: 678-842-8835 | Fax: 770-573-6826
info@purehealthmedicine.org
Marietta, GA 30068

Patient Referral

We try to ensure providing you the services as quick as possible, for that kindly provide maximum information in the form below. However, if there is further information needed, you will be contacted on the number given below by you.

    First Name

    Middle Name

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    Select Gender

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    Address

    Date Of Birth *

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    ZipCode

    Phone *

    Alternate Phone

    Email *

    Disciplines(Select All that Apply) *
    I understand that Pure Health Medicine only delivers care via Telehealth by a licensed medical professional.

    I accept

    Does the Patient attend School?

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    Preferred Schedule

    Patient and/or guardian First Name *

    Patient and/or guardian Last Name

    Primary Diagnosis *

    Secondary Diagnosis

    Referral Information

    Person Making Referral

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    Referral's Fax Number

    How did you hear about us?

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    Additional Information