Referral Form

Please click the button below to print and complete the referral form or fill it out online using the form at the bottom of this page.
Download & Print Form
Complete the referral form online
If not, the doctor on duty will treat as s/he feels appropriate.

Please attach any related radiographs or lab work

Click or drag a file to this area to upload.
Click or drag a file to this area to upload.
Click or drag a file to this area to upload.
Please inform clients of the following:
1. At EVS, they will be given an itemized estimate and asked to leave a deposit of the low end of the estimate.
2. Remaining fees are due and payable when the patient leaves EVS. We accept cash, all major credit cards, Scratchpay, and Care Credit.