Patient Referral

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Phone: 678-842-8835 | Fax: 770-573-6826
info@purehealthmedicine.org
351 Thornton Rd Ste 118 Lithia Springs, GA 30122 (By appointment only)

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HOME
About Us
Our services
PRICING
Patient Referral
Patient Portal
Forms
CONTACT
Blog

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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.

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Name *

First

Middle

Last

Select Gender *

Male
Female

Address *

Address Line 1

Address Line 2

City

State

Zip Code

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Email *

Phone *

Date of Birth *

Alternate Phone

Checkboxes *

I understand that Pure Health Medicine only delivers care via Telehealth by a licensed medical professional.

Does the Patient attend School? *

Yes
No

Preferred Schedule

Patient and/or guardian name *

First

Last

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Primary Diagnosis *

Secondary Diagnosis

Referral Information

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Person Making Referral

Referral's Phone Number

Referral's Email *

Referral's Fax Number

How did you hear about us?

Mailer
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Marketing Material
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Doctor's Office
Goverment Agency
Friend
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Patient Referral

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