REFERRAL FORM - ONLINE2 -

PATIENT REFERRAL
TBI QUESTIONNAIRE
SERVICES
EDUCATION
- SEMINARS
ABOUT
- ABOUT NBII
- DR HAIDER
- HOPE
- PRESS ROOM
- LOCATIONS
- FOLLOW US
- CAREERS
- CONTACT
Menu

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

or Download Form and submit via email or fax.

Click here for NBII Privacy Policy

For TBI Questionnaire click here.

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
- Unknown
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

Accepted file types: jpg, png, pdf, Max. file size: 128 MB.

Two Step Form – Return to Top of Page to Complete Form(s)

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

Refer A
Patient Here

National Brain Injury
Awareness Day
March 4, 2020

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

Click Here

Todos los miembros del equipo en NBII son bilingües, dominan el español y el inglés.

Referral Form received

Thank you. We will be in touch soon.