Medical Referral Form

Collaborative Care Starts Here

At Aligned Chiropractic, we value the power of collaborative healthcare. Our referral system is designed to make it easy for healthcare professionals to refer patients for chiropractic evaluation and care.

Whether your patient is seeking support for musculoskeletal issues, rehabilitation, or preventative wellness, our experienced chiropractors are here to help.

How to Refer a Patient

Please use the secure form below to refer your patient to our clinic. Our team will promptly follow up with both the referring provider and the patient to ensure timely care coordination.

Why Refer to Us?

Experienced and licensed chiropractors
Individualized, evidence-based care plans
Modern facilities with diagnostic capabilities
Transparent communication and progress updates for referring providers

Need assistance? Call us at (336) 996-7007 or CLICK HERE to email us.

Name:

Email:

Phone:

Preferred Contact Method?

	Telephone
	Email

Who can we thank for the referral?

Enter Verification Characters:

*required information