Patient Referral Form

Please fill out the following fields. Your patient will be scheduled for an evaluation within 2 weeks.

DO NOT USE FOR EMERGENCIES OR URGENT REFERRALS. If there is a medical emergency, contact the doctor or Lucy at 951-929-3399, or dial 911.

Patient Name*

Patient's Date of Birth*

Patient's Phone*

Phone

Patient's Email

If your patient has an HMO insurance plan, please refer them to their primary care doctor for pre-approval

Patient's Insurance Information

Referring Practice Name*

Referring Doctor's Name*

Referring Doctor's Phone #*

Referring Practice Fax #

Referring Doctor's Email*

Reason for Referral*

If the dropdown options do not accurately reflect your reason for referral, please feel free to type in your own response.

Select or enter value

Diagnosis Code (ICD-10)

MRx OD

MRx OS

VA's

Would you like to co-manage this patient?

Please include chart notes as they are helpful to your patient's appointment with IES doctors.

You can also fax chart notes to 951-704-7177.

Referring Provider's Chart Note / CCDA File -- Insurance Card Front & Back

Drag and drop files here or

Notes

Send me a copy of my responses