Referral Request Form

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All information must be filled out to process your referral request. Missing information will delay the processing of your referral. Thank you for your attention to detail.

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New Creation Healing Center
80 Route 125
Kingston, NH 03848-3535
Phone: (603) 642-6700
Fax: (603) 642-6701

Last Name:
First Name:
Phone #:
Date of Birth:

Current Insurance:
Insurance ID #:
Insurance Subscriber:

Date of appointment:
Reason for appointment:

Specialist's Name:
Specialist's NPI#:
Specialist's Street Address:
                                  City:
                                State:
                                   Zip:
Specialist's Phone #:
Specialist's Fax#:

Is the reason for this appointment:
Work Related
Auto Accident Related:

All information must be filled out to insure the speedy turn around of your referral request.
Please allow up to 7 days for your request to be processed.
Thank you!

"If anyone who believes in Christ is a new creation. The old is gone! The new has come! It is all from God. He brought us back to himself through Christ's death on the cross. And he has given us the task of bring others back to him through Christ. God was bring the world back to himself through Christ. He did not hold people's sins against them. God has trusted us with the message that people may be brought back to him. So we are Christ's official messengers. It is as if God were making his appeal through us. Here is what Christ wants us to beg you to do. Come back to God! Christ didn't have any sin. But God made him become sin for us. So we can be made right with God because of what Christ has done for us."
~2 Corinthians 5:17-21 New International Reader's Version