Please use this form for Referral Purposes, this is for the 5C affiliate charitable clinic use.
The form is very simple. Follow the steps below.
1- Choose what type of appointment you are seeking.
2- Complete filling out the form. The form will show you which one of our affiliated clinic has the care you choose in step 1.
3- Once completed the email will be sent to the 5C group email.
4- If you are one of the provider/clinic sending a referral for a patient of yours, please provide your name and contact information, so you are informed once the referral is received and followed upon.
That is it !!