External Clinician Referral Form (Part II)

Enter Patient Referral Data Here:

This is Part II of your Patient Referral Process. Please share patient information below, with their permission, and we will immediately begin communicating with them. They may opt out of our communication at any time.

Referring Clinician Information

Referral Source Email for Follow-up (please reenter) *

Name of Referring Clinician (please reenter)

How Can We Help?

Patient Referral Information (fields with * are required)

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.