Referral Form
Please include as much detail as you can — it helps us prepare before we ever call the patient. Fields marked with an asterisk in your browser are required.
For Referring Providers
Refer a Patient
If you have a patient whose headaches, dizziness, concussion after-effects, POTS, TMJ, tinnitus, brain fog, trigeminal neuralgia, or arm/hand numbness and tingling haven’t resolved with standard care, we’re glad to take a look. Every referral starts with a free consultation — no cost or obligation to the patient.
Prefer to call or fax it in instead? Reach our office at (636) 271-2960 or email info@gatewayuppercervical.com.
How Referrals Work
- Step 1
Submit the Referral
Fill out the form with the patient’s demographics, your contact information, and the reason for referral. Takes about two minutes.
- Step 2
We Call the Patient
Our office calls the patient directly — usually within one business day — to schedule a free consultation at a time that works for them.
- Step 3
Free Consultation
During the consultation, we discuss the patient’s issues, whether upper cervical care can help, and what a plan of care would look like — no obligation.
- Step 4
We Keep You in the Loop
If you’d like an update on a patient you’ve referred, call our office any time at (636) 271-2960.