Shield Clinics
Referral Forms
For Physicians Only
Please use this form to refer patients for ultrasound-guided injections. You may submit the completed form using the online submission below.
Referral Form
For general consultations, pain management, psychiatric support, or rehabilitation services. Fill out the patient’s details, reason for referral, history, and select the services needed.
Ultrasound-Guided Injection Form
For image-guided treatments targeting joints, tendons, or bursa. Complete the therapy selection, treatment area, and clinical history to ensure accurate care.