Bala Family Practice

I n-house X-Ray Services

Easy Prescription Refills

Doctor Referrals

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.

Patient's Name
First Last
Date of Birth *
MM / DD / YYYY
Enter Date of Birth
Email Address *

Confirm
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Daytime Phone *
Evening Phone *
Insurance Provider Information
Select Your Insurance Provider:
I would like to be contacted by Email or Phone: *

Email

Phone

Specialist Referral Information
Name of specialist you are requesting a referral to:
First Last
Date of your Appointment
MM / DD / YYYY
Town or City where Specialist is located
Please list the reason for referral request. Be brief, 30 words or less.
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Insurance Provider Information

Specialist Referral Information