Referring Physicians - Use This Form For Referrals

Patient & Visitor Information

Referring Physicians


Thank you for the opportunity of caring for your patients. Emed Multispecialty Group welcomes the opportunity to partner with you in caring for your patients. We are always available and committed to serving you and your patients.

Looking to refer a patient? We’ll try to make that easy for you. Please feel free to refer whichever way is convenient for you.

• Call (904) 513-3240 and ask to be connected to the New Patient Coordinators
Download and fax referral form to (904) 398-7871
• Request appointment online

Physician Online Referral Request Form

Do not use for scheduling urgent appointments. For an urgent appointment request, please call (904) 513-3240.
We’ll respond within 24 hours.

Used to refer patients for pain management.

"*" indicates required fields

Name of Physician Requesting Appointment
Who Should We Contact at Your Office?
May We Contact Patient Directly to Schedule Appointment
Patient's Name
MM slash DD slash YYYY
Best Time to Call During Office Hours? – Start
Best Time to Call During Office Hours? – End
Patient Address*
This field is for validation purposes and should be left unchanged.

Thank you very much for your referral. We review each packet and appropriate referrals will be scheduled for the soonest available intake appointment. If the packet is denied due to inadequate information, you will receive a notice requesting what is still needed.


We have decades of combined experience in primary care! Whether you have a cold or just need a checkup, we’re here for you!

Convenient communication, call or text.
Primary Care: (904) 513-3240
Pain Management: (904) 206-7132

© 2022 Emed Multispecialty Group. All rights reserved.