External Clinician Referral Form

Referring Clinician Information

Referring Clinician's Name *

Referral Source Email *

Referral Source Full Address, Fax & Phone

How Can We Help? *

Patient Referral Information

Patient Name *

Phone *

Email

Select the Insurance Provider *

(We do not take Medicare or Tenncare right now)

Interest *

As the referring clinic or clinician, I acknowledge and agree that I have received permission from the patient to enter their contact information. The patient understands they will receive texts, emails and calls from us in the process of getting them scheduled, and they may be required to fill out forms or pay co-pays or deposits to be seen. The patient still agrees to this referral. The patient may terminate communication from us at anytime if they do not want to move forward with scheduling.