Refer a Patient

Thank you for entrusting Flagstaff Bone & Joint with your patient's care.

Once we receive your referral, we will contact your patient directly within 24 hours to schedule an appointment.

Three Ways to Refer a Patient:

If you are a patient interested in making an appointment, please click here.

Referring Office Contact Information

Referring Physician

Your Name

Phone Number

Email Address

Fax Number (Optional)

If you would like a confirmation of your patient's appointment, please provide your fax number.

Patient Information

Patient Name

Date of Birth

Patient Phone Number

Alternative Phone Number

Email Address

Patient Insurance

Area of Specialty

Does this visit relate to a workers' compensation claim?

Yes

Patient Has Completed

Bone Scan

CT Scan

MRI

EMG

X-Rays

Cast/Splint Applied

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