Patient Referral Form

  • Parent or Guardian Information

  • Patient Information (Child’s Name)

  • Reason for Referral *

    (Check all that apply & include additional concerns below)

  • Patient Insurance Information

  • Preferred Location for Service of Patient

  • Please email your completed referral form to: Referrals@banyanhealth.org
    or please fax form to: 305-643-7801
    For referral questions please call: 305-900-4817