Refer a Patient and we'll Guide Them Through the
Insurance Process and Drug Administartion

Patient Referral Form


Start referring patients immediately by filling out our Patient Referral Form and fax it back to us.
There are four ways get in touch with RX Biotech - Telephone, FAX, E-Mail, or Online.

CLICK HERE TO FILL OUT AND SIGN OUR PATIENT REFERRAL FORM ONLINE AND FAX IT TO (310) 657-0906.

Telephone : (310) 657-2881, (800) 657-2212

Fax : (310) 657-0906 (print out and fax the form above)

E-mail info@RXBiotech.com (or you can email us the Patient Referral Form after filling out & sign)

Online Please take a moment to complete the Patient Referral Form. Rest assured that this information will be kept confidential.