Referral Form

Please complete our referral form and send it to us before your client’s appointment so we can review it in advance. The form is important for our reference and medical records. You may print and fax the referral form or complete the on-line form which will be securely emailed to us.

We also encourage you to call us if you would like to discuss the case in advance.

(816) 229-1544

(816) 228-9364

Please complete the on-line referral form and captcha
which will send us a secure email.

If you need to send us a general email rather than a referral form,
please use the Contact Us form or
staff [at]

NOTE: Email is routinely checked twice daily Mon-Sat except on holidays.
If this is an urgent referral please call us at 816-229-1544 to let us know
you have sent a referral form or email.

Mon thru Fri 7 AM to 7 PM
Sat 8 AM to 3:30 PM

1201 SW US Highway 40
Blue Springs, MO 64015


Click to print our referral form

– OR –

Submit Form On-Line

  • MM slash DD slash YYYY
  • Please include medication dosages, diet recommendations, diagnostics, treatments, and outcome of tests and treatments.
  • What diagnosis or differential diagnosis has been discussed with the client? What are they expecting during the referral?
  • Medical Records and Images

    PLEASE SEND COPIES OF THE MEDICAL RECORD INCLUDING DIAGNOSTIC TESTS AND/OR RADIOGRAPHS. Records may be faxed, sent with the client, uploaded with this form, or emailed. Use staff [at] to email digital radiographs or medical records.
  • Documents must be in pdf, doc, or docx formats. Images may be jpg, gif, or png. Files may not exceed 64 MB.
    Drop files here or
    Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 256 MB.