Please complete the referral form below in its entirety and return to us with relevant medical records including a complete medication list. You will recieve a call back from our office within 24 hours. You can fax the information to 570/348-1109 Attn: Donna.
|New Patient Referral Form||Please print and complete the form in its entirety. Fax the information to 570-348-1109 Attn: Donna.|