Referrals After filling the details click on the SUBMIT button. *indicates required fields    *Patient's name:   *Age:   *Custodian:   *Address:   *Phone number:   *Reason for referral:   *Payment:  Private pay  BC/BS Alabama  Other insurance Please review the admission and office policies sections. Be aware that youngsters can only be examined with authorization of their guardian or custodian. After completion click on the SUBMIT button.
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