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Referring Physicians

Patient Communications Form

We request that you complete the online form below.   

  • Provider Information

  • Patient Name

  • Desired Therapies

  • Therapy Goals

    Our AMT physicians can design a program or you can order if desired.
  • Our AMT physicians can design a program or you can order if desired.
  • Patient History

    We require CBC, CMP (including an eGFR) and a G6PD on most all IV patients.
    Which labs are completed within the past 60 days and are being sent to us?
    If High dose IVC, H2O2, Ozone, Artesunate are ordered then we need a Quantative G6PD (Lab Corp # 001917) or similar lab. Is this done and being sent? If not please order and have a copy sent to us. Please confirm in the checkbox above.
    If concerned about other lab values please contact an AMT physician prior to referral.
  • Any additional information for this referral and patient?