Refer a Patient

Thank you for entrusting The Hand & Upper Extremity Center of Georgia with your patients.

If you are a patient interested in making an appointment, please click here.

Please fill out the form below, and we will contact your patient directly within 24 hours to schedule an appointment.

To speak with a scheduler, please call our office directly at (404) 255-0226.

Referring Office Contact Information

Referring Physician

Your Name

Phone Number

Email Address

Fax Number (Optional)

If you would like a confirmation of your patient's appointment, please provide your fax number.

Patient Information

Patient Name

Date of Birth

Phone Number

Alternative Phone Number

Email Address

Patient Insurance

Requested Doctor

Was this injury/condition related to workers' compensation?

Yes

Patient Has Completed

Bone Scan

CT Scan

MRI

EMG

X-Rays

Cast/Splint Applied

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