Patient Referral

This is the medical referral form for doctors and other medical professionals necessary to begin our program.  If you are concerned about the health of one of your patient’s (between the ages of 6-19), please fill out the form below and fax it to 804-592-4752 or scan and email it to

Thank you very much for your support and we look forward to working with you.

Before and After



little green guyFor Doctors:


little green guyFor Parents:

I'd like to refer my child to your program.

Parent or Guardians Name (required)

Your E-mail (required)

Phone Number (required)


Please provide a brief message explaining how we can help

Please fill in the characters below in the box provided