Referral - Restoration Health | Spanish Fort Foley & Mobile Alabama

251-626-0732

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Physician Referrals

Your patients deserve world-class care and treatment.

Thank you for considering Restoration Health as a partner in the treatment of your patient. Please contact our office for additional information regarding our services and locations.

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FAX 251.216.4343

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CALL 251.626.0732

Patient Referral/Consult Request Form

Patient Name *

Phone *

Patient DOB *

Referring Physician *

Office Location Requested *

Requested Physician

J. Clay Rainer MD

David Thomason MD

Taylor Scruggs MD

Stefanie Miller CRNP

Ashley Greer PA-C

Daniel Rohrer CRNP

Ashlyn Fields CRNP

Sharon Ganey CRNP

Reason for Consult

Neck Pain

Mid Back Pain

Low Back Pain

Joint Pain (Please Specify Below)

Other

Does the patient have any X-Rays, MRI's, CT's, etc. of the area?

Yes

In what facility were the images taken? (Patient will need to bring a disc copy)

History of any prior treatment to the area? (surgeries, epidurals, pain mgmt, PT, etc.)

If you would like to be notified of the patient's appointment date & time please add your email below:

Fax Number (If needed for follow up)

Date

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Forms

Medical Release Form

Physician Referral Form

Convenient Locations

30762 State Hwy 181

Spanish Fort, Alabama 36527

1711 N McKenzie Street

Foley, Alabama 36535