Refer a New Patient – Referring Provider Offices Only

Refer a New Patient – Referring Provider Offices Only

Thank you for choosing OHC. If you are a new patient, please go to the Request a New Patient Appointment Tab or click below:

If you are an existing patient, please go to the Contact Us Tab or click below:

*Fields with a red asterisk are required

Patient Information

Patient First Name*

Patient Last Name*

Patient Gender

Male

Female

Other

Patient DOB*

Patient Primary Phone #*

Phone

Patient Email (If Known)

Referring Physician Name*

Referring Physician Office Phone #*

Phone

Referring Physician Email or Designated Clinical Team Member

To receive your patient appointment details (Date, Time, Office Location, and OHC Doctor) please provide an email address.

Name of Provider Requested

Please click here to see list of doctors and their locations: https://ohcare.com/for-medical-professionals/locations-phone-fax/

First Available

Reason for Visit or Diagnosis*

Service Requested*

Select

Urgency

Urgent (24 hours)

Immediate (48 hours)

First Available (3-5 Days)

Patient Record Upload

Please upload any relevant patient documents including their insurance card, if available

Drag and drop files here or

Why did you choose us?

Select

Send me a copy of my responses

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