Dr.Taher’s Referral Form

Referral Form - Dr Taher

"*" indicates required fields

MM slash DD slash YYYY
Patient Information
MM slash DD slash YYYY

Service Request
Interested In:*
Upload Scans (Radiographs)
The total combined max upload size is 30MB.
Drop files here or
Accepted file types: jpg, png, pdf, Max. file size: 30 MB, Max. files: 3.
    This field is for validation purposes and should be left unchanged.