Referring Physician

Enter your NPI, or your physician name and facility name.

NPI

Your details are looked up automatically from the national registry.

Physician Name

Practice / Facility Name

Your Phone

Your Email

Southlake: 3120 W. Southlake Blvd, Suite 140, Southlake, TX 76092

Lewisville: 405 SH 121 Bypass, Bldg A, Ste 150, Lewisville, TX 75067

Houston Medical Center: 7205 Fannin, Suite 110A, Houston, TX 77030

Willowbrook: 7927 Cypress Creek Pkwy, Suite 100, Houston, TX 77070

Phone: 877-797-LIFE (5433) | Fax: 866-290-8375 | Email: [email protected]

PHYSICIAN PORTAL

Select an order form below to fill out and submit electronically.

You may also fax completed orders to: 866-290-8375