Referral Request

Name: Balance Health
Address: Balance Health

We welcome your Patient Referrals!

Please fill out the form below and we will reach out to your referral immediately.

Referring Physician

Phone Number

Fax Number

PCP (if different from referring)

Patient Information
Last Name

First Name

Phone Number

Alternative Number

Date of Birth

Type of Insurance

Foot/Ankle Condition

Previous Treatment

Pertinent History/Additional Information

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Achilles Tendonitis

Amputation Prevention

Arthritis

Athlete’s Foot

Bunions

Clinical Research Trials

Cold Laser Therapy

Corns and Calluses

Diabetic Foot Care

Extracorporeal Pulse Activation Technology (EPAT)

Foot and Ankle Fractures

Foot and Ankle Surgery

Gout

Hammertoe

Heel Pain

Ingrown Toenail

Laser Toenail Fungus

Lower Extremity Sports Medicine

Nail Problems

Neuroma

Nevro HFX™ Diabetic Neuropathy Management

Orthotics

Pain and Inflammation Laser

Pediatric Foot Care

Peripheral Arterial Disease

Plantar Fasciitis

Platelet-Rich Plasma

Sports Injuries

Work Related Injuries

Wound Care

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Referral Request

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