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REFERRING PHYSICIANS

Our office offers convenient on-site access TO a full range of comprehensive services including Consultation or Evaluation and Management Services.

Urgent, next day, and early morning appointments are available. We offer free on-site parking and are centrally located near downtown.

Appointments may be scheduled by submitting the on-line referral request below, calling our office between the hours of 8:00 a.m. and 4:30 p.m., Monday through Friday or faxing a referral request form to our main fax line (614) 486-9665.

CAC Physician Referral Form (PDF 248KB) Please download and fill-out electronically in Adobe Reader or print and fill out by hand.

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PHYSICIAN APPOINTMENT/REFFERAL REQUEST

Referring Physician Information
Physician's Name:
Physician's Email:
Office Phone:
May we contact the patient
directly to schedule?
Yes   No
Scheduling Request: Next Available
Urgent (within 1 to 2 weeks)
Emergency
Patient's Information
First Name:
Last Name:
Date of Birth:  /   / 
Home Phone:
Work Phone:
Cell Phone:
Preferred Physician:
 
 

Our office offers convenient on-site access to:
Digital X-Ray
Bone Density Testing
Lab Services
Infusion Services
Open Extremity MRI
Physical Therapy
Occupational Therapy
Wellness Programs
Research Programs