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Jaime Ballesteros M.D.
May 20th, 2018

Referral Form
Patient: Patients in need of an EMG must have a referral from their primary care physician. The EMGflint Referral form must be completed by patients’ referring and/or primary care physician and faxed to 810-732-4344. The completed referral will be returned to the patient and must be brought to the appointment. Your referring and/or primary care physician will advise patient of appointment date and time. Please print the form below and have your referring and/or primary care physician complete. The office will need to fax completed form to EMGflint at 810-732-4344.
Referring Physician: Please complete form and fax to 810-732-4344. The office will respond with appointment date and time.

Jaime Ballesteros M.D

Board Certified
Electrodiagnostic Medicine

G3239 Beecher Rd Suite C
Flint, MI 48532
Phone: 810-732-9222
Fax: 810-732-4344.

Tulane University Hospital
Hurley Medical Center