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Serving All of East Texas
Longview, TX:
405 Magrill St
.
903-502-0490
Se habla español
Referral Form to Dr. Skarda
Referring Clinician
Referring Clinician’s preferred means of secure communication/email:
Client First Name
*
Client Last Name
*
Client's Phone
*
Client's Email
*
Client's Age
Month
Month
Day
Year
Allergies
*
Current doctor/PCP
*
Current Medications
*
Presenting Issue/Working Diagnosis:
*
Additional Comments/Requests
Submit
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