Phone: 678-842-8835 | Fax: 770-573-6826
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

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

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    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 *

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    Additional Information