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

Please inform clients of the following:
1. At EVS, they will be given an itemized estimate and asked to leave a deposit of approximately ¾ of estimate.
2. Remaining fees are due and payable when the patient leaves EVS. We accept cash, approved check, all major credit cards, and Care Credit.