For referring providers
Fax a Referral
We work alongside your practice to get patients seen quickly — and we keep you in the loop.
The referral form
Print the form, complete it with your patient's information, and fax it to our office with the supporting documents listed below. Mark it STAT if the patient needs to be seen urgently.
Download the referral form (PDF)Where to send it
Fax(928) 395-4007
Phone(928) 395-3296
Please fax patient information rather than emailing it — our email inbox is not a secure channel for protected health information.
Please attach
- 1Patient demographics
- 2Insurance information
- 3Medical records including the last three visits
The form asks for
- Primary diagnosis / chief complaint
- Cervical pain · Lumbar pain · Thoracic pain · Joint pain · Other
- Referral type
- Evaluate and treat, or personal injury — with number of visits and follow-ups
- Scheduling priority
- First available, or STAT
- For personal injury referrals
- Attorney or adjuster name and phone number
What we can take on
Procedures we perform
Epidural Steroid Injections
An epidural steroid injection (ESI) is a minimally invasive medical procedure that delivers a strong anti-inflammatory corticosteroid (often mixed with a local anesthetic) into the epidural space surrounding the spinal cord and nerve roots.
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Selective Nerve Root Injections
A selective nerve root injection (SNRB) is a minimally invasive medical procedure where a local anesthetic and a long-lasting steroid (cortisone) are injected directly around a specific spinal nerve root as it exits the spinal column.
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SI Joint Injections
A SI (sacroiliac) joint injection is a minimally invasive procedure that delivers a local anesthetic and/or corticosteroid medication directly into the sacroiliac joint, which connects the lower spine (sacrum) to the pelvis (ilium).
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Radiofrequency Ablation
Radiofrequency Ablation (RFA) is a minimally invasive, non-surgical pain-management procedure that uses heat generated by radio waves to temporarily disable specific small sensory nerves (such as the medial branch nerves) in the spine.
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Caudal Epidural
A caudal epidural—often called a caudal epidural steroid injection (CESI)—is a minimally invasive medical procedure where a steroid and local anesthetic are injected into the lowest part of the epidural space near the tailbone.
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Shoulder Injections
A shoulder injection is a minimally invasive medical procedure that delivers medication directly into the shoulder joint or surrounding soft tissues to reduce pain and inflammation.
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Knee Injections
Orthovisc / Synvisc
Knee injections are treatments delivered directly into the knee joint to reduce pain, lower inflammation, or improve joint lubrication.
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Elbow Injections
An elbow injection is a medical procedure that delivers medication directly into the elbow joint space, bursa, or surrounding tendons to relieve severe pain, reduce inflammation, and improve movement.
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Occipital Block
Migraines
An occipital nerve block is a quick medical injection of numbing medicine and an anti-inflammatory steroid near the occipital nerves at the base of the skull to temporarily stop head and neck pain.
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Neuro Stimulator
Spinal cord & peripheral nerve stimulation — trials and permanents
A nerve stimulator is a medical device that sends mild electrical impulses to block or alter pain signals before they reach the brain.
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PRP for Joint Injections
FDA approved for degenerative joint disease, wound care
Platelet-rich plasma (PRP) for joints is a regenerative therapy that uses a concentrated dose of a patient's own blood platelets to reduce joint pain, lower inflammation, and stimulate natural healing in damaged tissues.
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A dawn to a better you
Questions before you refer?
Call the office and we will talk through whether your patient is a fit — and how quickly we can see them.