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Please complete the form below then sign and click “Submit.”  Accompanying medical records will need to be faxed to the preferred location using the following numbers.

Tulsa Fax:  (918) 252-7466                Tulsa – Aesthetic & Laser Center Fax:  (918) 940-2970               Grove Fax:  (918) 787-7940

McAlester Fax:  (918) 302-3088         Muskogee Fax:  (918) 687-6610

Physician Referral Form

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