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Desert Medical Advances
Advances In Medicine
72855 Fred Waring Drive, A-6
Palm Desert, CA.  92260
760-341-6800


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: 760-341-9777 or 760-341-6800

Print out this form, fill it in and either mail it, drop it off at the office or fax it to 760-341-9872.

Name:______________________________________________

Phone:_____________________________

Address:__________________________________________

City:_________________________   State:____________ ZIP:_______________

List medications you are presently taking: _____________________________________________________________

________________________________________________________________

Do you have asthma?  Y   N
Hay fever?  Y   N
Lung disease?  Y   N
Have you smoked less than 10 years?  Y   N
Have you smoked more than 10 years?  Y   N
Do you have arthritis?  Y  N
If yes, what type? _______________________
Do you have an autoimmune disorder?  Y  N
If yes, what type? _______________________

Note:  FDA generally excludes anyone who is pregnant, had cancer in the past 5 years (certain squamous or basal skin cancers are not excluded), or has significant renal or liver dysfunction.

Person sending this form:_________________________________________________