You may refer patients to our office by filling out our HIPAA secure online Referral Form.  After you have completed the form, please press Submit to send us your referral. 

Note: You may zoom in on the form by clicking the magnifying glass on the upper right of the form.



The security and privacy of patient data is one of our primary concerns.  All of our forms are secured to standards compliant with HIPAA.  You may submit your referral by fax to 850.523.0831.  You may also print our referral form, and then scan and email to  If you would like to provide your patient our registration form, you may print it below.  


Please remember to send imaging to!