Referral Form in Dallas TX 75231 | Premier Health Chiro Med

Contact or Refer to Provider

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Referral Request

Refer to*

Provider

Specialty

Provider*

Specialty*

Referring Physician Information

Name*

First Last

NPI#*

Practice Contact Information

Full Name*

Location*

City State

Phone*

Fax

Patient Information

Name*

First Last

Preferred Phone*

Alternate Phone

Date of Birth

Type of insurance*

Appointment Information

Appointment Time Requested, E.g. < 3 days, 1 week, patient convenience*

Additional comments about this referral

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Our providers exist to partner with physicians through providing the highest level of special care for patients, identifying opportunities to better serve referring physicians, and facilitate ease of interaction with Premier Health Chiro Med. We strive to create relationships that bring value to physicians and patients in the near future. Our dedication is to consolidate the medical and chiropractic profession.

Get In Touch

Premier Health Chiro Med

Call Us: (214) 265-9000

Visit Us: 9669 N Central Expy
Suite 200
Dallas, TX 75231

Office Hours

Monday: 8:00 AM – 1:00 PM & 3:00 – 6:00 PM
Tuesday: 10:00 AM – 1:00 PM & 3:00 – 6:00 PM
Wednesday: 8:00 AM – 1:00 PM & 3:00 – 6:00 PM
Thursday: 10:00 AM – 1:00 PM & 3:00 – 6:00 PM
Friday: 8:00 AM – 1:00 PM
Saturday: 9:00 AM – 12:00 PM
Sunday: Closed

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