Patient Referral Form

Please fill out the form below and click submit to email your referral. If you prefer to fax, a printer friendly version is available. Just click the link above for an Adobe PDF referral form. Medical records can be mailed or faxed to:

Kelly Quick, MRC, CRC                            Fax: (859) 388-2093
291 Burke Road
Lexington, KY 40511


Referral Information

Client Information

Employer Information

Attorney Information


Special Instructions