New Patient Referral Form
Please complete this form when referring a patient to Ideal Option
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient State of Residence
*
Please Select
Alaska
Arkansas
Idaho
Maryland
Montana
New Mexico
North Dakota
Oregon
Washington
Patient Zip Code
*
Used to determine closest clinic
Patient Phone Number for Calling
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Phone Number for Texting (if different)
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email Address
example@example.com
Preferred Date of Appointment
*
-
Month
-
Day
Year
Date
Preferred Time of Appointment
*
Early Morning
Late Morning
Early Afternoon
Late Afternoon
Patient Insurance Plan Name
*
If no insurance, please enter "uninsured"
Patient Insurance Membership Number
Please provide if available
Is the patient aware they are being referred to Ideal Option?
*
YES
NO
How will the patient get to the clinic?
Has transportation (own car, ride from friend, bus, etc)
Will need assistance with transportation
Will need remote intake for first visit (all states except AR)
Don't know
Other
Please provide more information about the patient being referred.
What is your name?
First Name
Last Name
What organization do you represent?
*
What is your email address?
*
example@example.com
What is your phone number?
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: