Already Have a VA Referral?

Complete the secure form below, and a member of our team will contact you regarding referral, authorization, and scheduling requirements.

Patient Information

Veteran's Full Name *

Full Name

Email *

Best telephone number *

Last four digits of Social Security number

Referring VA facility

Authorized provider

Approved service or specialty

Authorized dates and number of visits

Additional Information

Notice: Submitting information does not guarantee coverage or appointment approval.

We must verify that the referral is active and that the requested service is included in the authorization.

By checking this box, I consent to receive non-marketing text messages from Detoxity Holistic MediSpa regarding my appointment request, referral status, authorization updates, scheduling, and other healthcare-related communications. Message frequency may vary. Message and data rates may apply. Reply HELP for assistance or STOP to opt out.

By checking this box, I agree to receive occasional marketing and promotional text messages from Detoxity Holistic MediSpa, including wellness updates, special offers, events, and service announcements. Message frequency may vary. Message and data rates may apply. Reply HELP for assistance or STOP to opt out.