To complete the referral, download, complete, and fax this form back to our office at 317-948-5766, or call your referral information to the POWER Clinic at 317-948-5888.
Upon receipt of this referral the patient will be sent an intake questionnaire to be completed and returned to the POWER program before scheduling of the initial visit.
Once the completed forms are received by POWER, patients will be contacted and the initial visit of the 6 month program will be scheduled. At that time, your office will be made aware of the patient start date and progress throughout the clinic.