Patient Referral Services

Are you or someone you know struggling with ear-related issues? Look no further! Dr. Nazarian, a distinguished specialist in ear treatment and surgery, is here to provide top-notch care and comprehensive solutions.

Our patient referral services make it easy for friends and family to connect with Dr. Nazarian. Streamlined and efficient, the referral process ensures a smooth transition to specialized care.

SUBMIT a patient referral

Submit a Patient Referral

Please complete the form below. After you submit this information, a representative will contact you by phone.

Practitioners form

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01 EAR CONDITIONS & REFERRAL FOR

PLEASE SELECT THE CONDITION*(Required)

WHO IS THIS REFERRAL FOR*(Required)

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02 Patient information

FIRST NAME*(Required)

LAST NAME*(Required)

DATE OF BIRTH*(Required)

GENDER*(Required)

PHONE*(Required)

EMAIL*(Required)

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03 HEALTH INSURANCE

PRIMARY INSURANCE

POLICY NUMBER

Reason for Visit/Patient Diagnosis (OPTIONAL)