New Patient Referral

Patient Referral Form

Please complete and send this form. We will contact you as soon as possible. If you have any questions about this form, you can Call / Text: 8324496276 to send us a message.

Patient's First Name

Patient's Last Name

Patient's Date of Birth

Patient's Gender

Patient's Telephone / Mobile

Patient's Email Address

Reason for Referral

Patient's Payment Method

Insurance (In-Network) Self-pay (No insurance or out-of-network)

Patient's Pharmacy name and address?

(1a) Patient's primary health insurance company

(1b) Patient's primary insurance policy number

(1c) Patient insurance plan group number

(2a) Patient's secondary health insurance company (if any)

(2b) Patient's secondary insurance policy number

How did you come across our company?

Any other information / comment you need to share?

Name of Referrer

Referrer's Organization or company

Referrer's business email

Referrer's business Phone number

Referrer's business Fax number

Upload referral document(s) if any

Consent

I consent to the collection and processing of the data provided in this online form, in accordance with the applicable privacy policy, for the purpose of providing mental health services. I understand that the information will be used solely for the intended purpose and will not be shared with third parties without my explicit consent. I also acknowledge that I have the right to withdraw this consent at any time by contacting GrowthFairness Psychiatry, PLLC.

Hours of operations: Monday to Saturday 9am to 7pm.

8324496276

[email protected]

New Patient Referral

Patient Referral Form

GrowthFairness Psychiatry, PLLC.

Fax:

7135541811.

Email:

BUSINESS ADDRESS:

12337 Jones Road,Houston Texas 77070.

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