Attorney Referral Form
PROVIDERS
Select Provider:
*
Sridhar Vasireddy, M.D.
Urfan Dar, M.D.
Stephanie Jones, M.D.
Justin Vigil, M.D.
James Houston, P.A.
Blesson John, PA-C
Dora Trevino, DNP, APRN, FNP-BC
First Available Provider
Other
LOCATION
Select Location:
San Antonio (Stone Oak) — 20079 Stone Oak Pkwy #1245, San Antonio, TX
San Antonio (Southside) — 102 Palo Alto Rd, San Antonio, TX 78211
San Antonio (Medical Center) — 9130 Wurzbach Rd Ste 102, San Antonio, TX 78240
San Antonio (Alamo Heights) — 332 W Sunset Rd, Suite 3, San Antonio, TX 78209
San Antonio (Athena Surgery Center) — 19296 Stone Oak Parkway, San Antonio, Texas, 78258
San Antonio (Vertex Surgery Center) — 1927 Rogers Road, San Antonio, Texas , 78251
New Braunfels — 790 Generations Drive, Suite 405B, New Braunfels, TX 78130
Ingram (Kerrville/Fredericksburg) — 3350 Junction Highway, Ingram, Texas 78025
No preference - earliest available location
REFERRAL INFORMATION
Referring Attorney:
*
First Name
Last Name
Attorney Firm:
Referring Provider Contact:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referred Patient:
*
First Name
Last Name
Referred Patient Contact:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Date of Birth:
*
-
Month
-
Day
Year
Date
Reason for Referral:
*
Please fax patient's records to:
210-545-3455
Submit
Should be Empty: