Physician Referrals

Dr. Paglia and his team are dedicated professionals who care about your time
and resources and will provide personal attention to your office and
patients. Recognized for Compassion, Results, Comfort, and Safety, you can
trust us to provide your Patient with the best treatment and level of care
as we would extend to our own families.

Referring patients to Atlantic Pain
Management and Wellness is quick and easy !

Simply fill out the information below and click on Submit and our office
staff will complete the intake process. If you already have this information
on your form, fax it to us at 954-699-0043. Should you need to discuss a
particular patients need before referring the patient to us, do not hesitate
to contact us at 954-458-1199.

  • Patient Name*full name
    0
  • Patient Phone*full name
    1
  • Patient DOB*make a booking
    2
  • Patient Address*full name
    3
  • Patient Email*a valid email address
    4
  • Patient Cellphone*full name
    5
  • Primary Insurance*full name
    6
  • ID#*full name
    7
  • Secondary Insurance*full name
    8
  • ID#*full name
    9
  • Referring Physician*full name
    10
  • Physician Phone Number*full name
    11
  • Request an Appointment Date*make a booking
    12
  • Workers Comp*select just one
    Yes
    No
    13
  • Medications*something more
    14
  • Diagnosis*something more
    15
  • 16

If an Authorization is required, fax us a copy to 954-699-0043. Please
ensure you have provided a copy of the referral to your patient.

Thank You for your Patient Referral !

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