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Provider Referral

To refer a patient, please:

Fill out the form on this page, or
Fax your referral to 323-978-6919

Our team will contact the patient directly to coordinate scheduling and next steps.

Thank you for trusting us with your patient's care.

Questions regarding a referral? Please call our office at 310-505-6096.

Physician Office Information

Practice Name*

Referring Provider*

Contact Person*

Contact Person Phone*

Contact Person Fax*

Patient Information

First Name*

Last name*

Patient Phone*

Patient Email*

Reason for Referral

Reason*

Pelvic Pain

Pregnancy/Postpartum

Urinary Dysfunction

Bowel Dysfunction

Sexual Dysfunction

Men's Pelvic Health

Orthopedic + Pelvic Health

Other

Insurance

Single choice*

Blue Cross Blue Shield PPO

Other PPO

Cash pay

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For any questions, feel free to contact us at 310-505-6096 or connect@theaurialife.com.

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C O N T A C T U S

Phone : 310-505-6096

Fax: 323-978-6919

connect@theaurialife.com

8929 S. Sepulveda Blvd. Suite 412

Los Angeles, CA 90045

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Provider Referral

To refer a patient, please:

Fill out the form on this page, or

Fax your referral to 323-978-6919

​

Our team will contact the patient directly to coordinate scheduling and next steps.

Thank you for trusting us with your patient's care.

​

Questions regarding a referral? Please call our office at 310-505-6096.​

Get in Touch

Questions regarding a referral? Please call our office at 310-505-6096.