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Patient Referral Form PDF

This is our patient referral form(physician order form) for new & existing dialysis clinics. Feel free to download & make copies as needed.

Fax form to: 412-276-9033

Email: referrals@tma-wpma.com

Only Medical Professionals can fill in the form.

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Come in and watch a procedure

If you are a medical professional, you can give us a call to schedule a time to come in and watch a procedure in person.  Pretty cool right?

Call us at: 412-276-9030

or fill out the form below

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Patient Referral Form Fillable PDF 

This is our patient referral form (physician order form) for new & existing dialysis clinics. Feel free to download or fill in right online.

Fax form to: 412-276-9033

Email: referrals@tma-wpma.com

Only Medical Professionals can fill in the form.

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Required Patient Documents

Please fax the following documents with the Patient Referral form(physician order form):

Facesheet/Insurance info

Co-Morbids

Lab Results

Patient Medication List

Fax form to: 412-276-9033

Email: referrals@tma-wpma.com

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