If you use a word processor and would like to have
both the Medical Authorization and DES Questionnaire forms automatically emailed to you,
just enter your desired file format and email address below:
Otherwise, print out and complete this
form then fax it back to:
Patricia Martin Stanford, PA
8402 Papelon Way
Jacksonville, FL 32217
Phone: (904) 733-1732
Fax: (904) 739-2347 |