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Fill out the form below
A member of the NBII Referrals will contact you via email regarding details.
Once all necessary items are received, our Scheduling Team will contact and schedule the patient.

Online Referral Form

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Patient Information
Today's Date (MM/DD/YY)*
Patient First Name*
Patient Last Name*
Patient Email
Patient Phone Number*
Gender*
- Male
- Female
Date of Birth (MM/DD/YY)*
Law Firm Name
Law Firm Phone Number
Referring Doctor Name
Referring Doctor Phone Number
Attorney Name
Attorney Email
Attorney Phone
Your First Name (Submitting this Form)*
Your Last Name (Submitting this Form)*
Your Phone Number (Submitting this Form)*
Your Email (Submitting this Form)*
Preferred Pharmacy Name
Fax Number*
Preferred Pharmacy Phone Number
Reason For Referral
Symptoms/Indications (select all that apply)*
- Headaches/Migraines
- Memory and/or Concentration Problems
- Inability to Focus and/or Attention Problems
- Blurry/Double Vision
- Depression
- Anxiety
- Personality Changes
- Brain Bleed/Swelling
- Abnormal CT and/or MRI of Brain
- Sensitivity to Light or Noise
- Mental Fogginess
- Dizziness/Balance Problems/Ringing in Ears
- Alteration of Speech/Abnormal Speech
- Post-Traumatic Stress Disorder (PTSD)
- Mood Swings
- Sluggishness/Lethargy/Fatigue
- Neck Pain
Any Other Symptoms?
Date of Injury (MM/DD/YY)*
Commercial?*
- Yes
- No
Mechanism of Injury*
- MVC
- Blast
- Fall
- Electrocution
- Industrial Accident
- Toxic Gas
- Other
Services Requested*
- CTE - Comprehensive TBI Evaluation
- CDR - Comprehensive Diffusion Tensor Imaging
- LDR - Limited Diffusion Tensor Imaging
- LCP - Life Care Plan
- NAB - Neuropsychological Assessment Battery
- TBIS - Traumatic Brain Injury Screening
- MCP - Medical Costs Projection
- SMER - Subject Matter Expert Report
Patient Preferred Language*
- English
- Spanish
- Other
Miscellaneous Notes
Select Location
Choose the closest location:
- Houston (Main Office): 6161 Savoy Dr, Ste 550, Houston, TX 77036
- Dallas: 7800 N Stemmons Fwy Ste 340 Dallas, TX 75247
- San Antonio: 110 Broadway St, Ste 60, San Antonio, TX 78205
- Los Angeles: 3530 Wilshere Blvd Ste 1230 Los Angeles, CA 90010
- Orlando: 611 N Wymore Rd, Ste 603, Winter Park, FL 32789
- Phoenix: 10000 N 31st Ave, C314 Phoenix, AZ 85051
- Tampa: 3825 Henderson Blvd, Ste 204 Tampa, FL 33629
- Sacramento: 1851 Heritage Ln, Ste 160 Sacramento, CA 95815
- Berkeley: 2915 Telegraph Ave, Ste 302 Berkeley, CA 94705
- Fresno: 7255 N Cedar Ave, Ste 102, Fresno, CA 93720
- Jacksonville: 9424 Baymeadows Rd, Ste 210 Jacksonville, FL 32256
- Iselin: 2000 Middlesex Essex Turnpike, Ste 106, Iselin, NJ 08830
- Miami : 1330 Coral Way Ste 210, Miami, FL, 33145
- Out of Town - Select if none of the options above apply
Diagnosis Imaging Studies in all Fifty States
Attach Supporting Documents
Clinical notes, imaging results, etc.
Drop files here or

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CLINICAL/TREATMENT LOCATIONS
HOUSTON: 6161 Savoy Dr, Ste 550, Houston, TX 77036
SAN ANTONIO: 110 Broadway St, Ste 60, San Antonio, TX 78205
DALLAS: 7800 N Stemmons Fwy, Ste 340, Dallas, TX 75247
LOS ANGELES: 3530 Wilshire Blvd, Ste 1230, L.A., CA 90010

SACRAMENTO: 1851 Heritage Ln, Ste 160, Sacramento, CA 95815

BERKELEY: 2915 Telegraph Ave, Ste 302, Berkeley, CA 94705

FRESNO: 7255 N Cedar Ave, Ste 102, Fresno, CA 93720

ORLANDO: 611 N Wymore Rd, Ste 603, Winter Park, FL 32789

JACKSONVILLE: 9424 Baymeadows Rd, Ste 210, Jacksonville, FL 32256

TAMPA: 3825 Henderson Blvd, Ste 204, Tampa, FL 33629
**PHOENIX: 10000 N 31st Ave, C314, Phoenix, AZ 85051

ATLANTA: 1440 Dutch Valley Pl NE, Ste 985, Atlanta, GA 30324

**NEW ORLEANS : 4621 W Napoleon Ave, Ste 210, Metairie, LA 70001

**ISELIN : 2000 Middlesex Essex Turnpike, Ste 106, Iselin, NJ 08830

MIAMI : 1330 Coral Way, Ste 210, Miami, FL 33145

** BY APPOINTMENT ONLY

USA IMAGING LOCATIONS
Approved DTI Imaging Facilities Click Here

USA IMAGING LOCATIONS
Approved DTI Imaging Facilities Click Here

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National Brain Injury
Awareness Day
March 4, 2020

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Sign the White House Petition
To Establlish A National Concussion Protocol Act in Each State

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