Referral Form
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Desert Medical Advances is associated with Advances in Medicine and together we offer new treatments for several diseases, free of charge.  All programs have been reviewed by the FDA.  The medications are being evaluated for significant advances either treating illness better or safer.  All patients participating in these programs can stop at any time.

For more information call: 341-4658

Print out this form, fill it in and either mail it, drop it off at the office or fax it to 341-4836.

Name:______________________________________________

Phone:_____________________________

Address:__________________________________________

City:_________________________   State:____________ ZIP:_______________

List medications you are presently taking: ____________________________________________________________________________________________

____________________________________________________________________________________________

Note:  FDA generally excludes anyone who is pregnant, had cancer in the past 5 years (but squamous or basil skin cancers are not excluded), or has significant renal or liver dysfunction such as over two times normal lab values.  Current estrogen use would preclude a new estrogen program.   Call if you are on coumadin or steroids.

Person sending this form:_________________________________________________