In-house X-Ray Services
Our mission is to provide affordable best in class health care:
  - Affordable/Convenient - Same day/Weekday/weekend appointments
   - Most services available in premise (Lab/X-Ray/Pharmacy etc)
   - Contact us at your convenience via internet/phone/email
Bala Family Practice: Physician Referral Form

The purpose of this form is to aid you in requesting a referral from your Primary Care Physician. The information you provide will be presented to your doctor for consideration of your request.

We will make every effort to accommodate you, and will notify you within 10 working days of your doctors recommendation. Please be advised that requests received on Fridays, Saturdays, Sundays or holidays will not be processed until the following business day.
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    Enter Date of Birth

  • Insurance Provider Information

  • Specialist Referral Information

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