By submitting this referral form, the referring physician certifies that appropriate patient consent has been obtained and that the provided information is accurate to the best of their knowledge.
CONFIDENTIALITY: This referral and its contents are confidential and will only be disclosed to authorized entities involved in the patient's care.
NO ESTABLISHMENT OF A DOCTOR–PATIENT RELATIONSHIP: Submission of this referral does not constitute formation of a doctor–patient relationship with the receiving provider.
Thanks for submitting the form.
