Academic Buffalonias in Physical Medicine and Rehabilitation, P.C.
4247 Maple Road, Suite A, Buffalo, NY 14226
2121 Main Street, Suite 210, Buffalo, NY 14214
Phone: (716)832-1000 Fax: (716)832-1001
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Physician Referral Form
This form will be faxed back to your office within 24 hours with appointment date and time.
Patient Name:
Patient Name is required.
Date of Birth:
Address:
Gender:
Male
Female
City:
Home Phone:
Patient Phone Number is required.
State:
Cell Phone:
Zip Code:
Work Phone:
Insurance:
ID #:
Special needs:
Diagnosis:
A value is required.
Reason(s) for Referral:
A value is required.
Referring Physician:
A value is required.
Physician's Phone #:
A value is required.
Pain Management and Rehabilitation Consultation
EMG / NCS
Acupuncture
Neuron-Rehab
Spinal/Musculoskeletal
Injections
Pain Management
Botox
Rehabilitation
Electrodiagnostic (EMG/NCS) Consultation
LUE
RUE
BUE
Coumadin anticoagulation
LLE
RLE
BLE
Cardiac Defibrillator
Brain Stimulator
Somatosensory / Dermatomal Evoked Potentials (S/DEP)