When you’re ready to refer your patient, simply complete the form below. We’ll contact you and your patient as soon as we receive your referral. If you have any questions, feel free to send an email to email@example.com.
Sending Images & Radiographs: If you need to send more than 5 images or radiographs, or files larger than 5MB, please use WeTransfer. WeTransfer is a free-to-use service for sending large files online. Please use firstname.lastname@example.org to transfer your file using WeTransfer. Need help? Here’s how to send a transfer.
Patient Referral Form: Some Practice Management Systems (PMS) allow you to export or download a patient referral form. If this applies to you, select ‘yes’ when asked ‘do you wish to upload a Patient Referral Form?’ If you need to manually upload a patient referral, then select ‘no’ to the previous question.