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Ace Physician Services
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Ace Physician Services
FAX REFERRAL FORM TO #832-460-3110 ALONG WITH SUPPORTING DOCUMENTATION
PATIENT INFORMATION
REFERRAL TYPE
Evaluate and Treat
Direct Schedule
Private Pay
Work Comp
DOL
Personal Injury
Attorney Name/Number
REFERRAL SPECIALTY
Neurosurgeon / Spine
Orthopedic
Pain Management
General Surgury
Cardiologist
Chiropractic
Physical Therapy
Gastroenterology
Bariatric
Plastic Surgeon
Podiatry
Gynecologist
Sleep Study
REFERRAL INFORMATION
Priority
Urgent (24 hours)
High (3-4 days)
Routine
IMAGING
MRI
Ultrasound
X-rays
EMG
CT
Body Part
Other
DME
Cervical Brace
Lumbar Brace
Bone Stimulator
Walker
Other
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