Memory Screening Order & Referral

This is offered by Pinnacle at no cost to the patient.
Insurance information and CPT codes are not needed.

Memory Order Form

Patient First Name

Patient Last Name

Patient DOB

Phone

Ordering Provider

Ordering Provider Phone

Ordering Provider Fax

Please fax the completed form, or send your EMR Entry Request to the location of your choice:

Georgetown | 3201 S. Austin Ave. Ste. 325, Georgetown, TX 78626 | F: (737) 444-8480

Brownsville | 717 N. Expressway 77/83 Ste. 6-9, Brownsville, TX 78520 | F: (956) 468-3365

Edinburg | 2502 W. Trenton Rd. Edinburg, TX 78539 | F: (956) 394-1173

Dallas (Presbyterian Hospital) | 8198 Walnut Hill Lane Jackson Dallas, TX 75231 | F: (214) 583-2278

New Jersey | 195 Mountain Ave. Springfield, NJ (973) 850-4621

New Jersey | 1144 East Ridgewood Ave Ridgewood, NJ 07450 | F: (973) 850-4621

Dallas (Oak Cliff) | 4315 S Lancaster Road Suite 170 Dallas, TX 75216 | F: (214) 583-2278

North San Antonio | 5109 Medical Dr Ste 200, San Antonio, TX 78229 | F: (210) 572-5766

Austin | 8015 Shoal Creek Blvd, Suite 114, Austin, TX 78757 | F: (512) 732-9957