5C Referral Form

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.

Thanks

That is it !!
Which service are you seeking the referral/appt.?*
Cardiology

These are the clinics that offer the specialty you have selected.

Hope Clinic - McKinney - https://hopeclinicmckinney.org/
Dermatology

These are the clinics that offer the specialty you have selected.

Woven Health Clinic - https://wovenhealth.org
Endocrinology

These are the clinics that offer the specialty you have selected.

Julia's Center - http://www.juliascenter.com/
Epileptology

These are the clinics that offer the specialty you have selected.

EPIC Medical Clinic - https://epicmedicalclinic.org
Family Medicine

These are the clinics that offer the specialty you have selected.

Community Health Center McKinney - http://www.chc-mckinney.com

Hope Clinic - McKinney - https://hopeclinicmckinney.org/

EPIC Medical Clinic - https://epicmedicalclinic.org

Julia's Center - http://www.juliascenter.com/

Woven Health Clinic - https://wovenhealth.org
Gastroenterology

These are the clinics that offer the specialty you have selected.

Community Health Center McKinney - http://www.chc-mckinney.com

Julia's Center - http://www.juliascenter.com/
GYN

These are the clinics that offer the specialty you have selected.

Community Health Center McKinney - http://www.chc-mckinney.com

EPIC Medical Clinic - https://epicmedicalclinic.org

Hope Clinic - McKinney - https://hopeclinicmckinney.org/
HIV/AIDS

These are the clinics that offer the specialty you have selected.

Health Services North Texas - https://www.healthntx.org/
Internal Medicine

These are the clinics that offer the specialty you have selected.

Community Health Center McKinney - http://www.chc-mckinney.com

Hope Clinic - McKinney - https://hopeclinicmckinney.org/

EPIC Medical Clinic - https://epicmedicalclinic.org

Julia's Center - http://www.juliascenter.com/

Woven Health Clinic - https://wovenhealth.org
Nephrology

These are the clinics that offer the specialty you have selected.

EPIC Medical Clinic - https://epicmedicalclinic.org
Neurology

These are the clinics that offer the specialty you have selected.

EPIC Medical Clinic - https://epicmedicalclinic.org

Woven Health Clinic - https://wovenhealth.org
Oncology

These are the clinics that offer the specialty you have selected.

EPIC Medical Clinic - https://epicmedicalclinic.org
Optometry

These are the clinics that offer the specialty you have selected.

Hope Clinic - McKinney - https://hopeclinicmckinney.org/

Julia's Center - http://www.juliascenter.com/
Orthopedic

These are the clinics that offer the specialty you have selected.

Julia's Center - http://www.juliascenter.com/
Pulmonology

These are the clinics that offer the specialty you have selected.

EPIC Medical Clinic - https://epicmedicalclinic.org
Rheumatology

These are the clinics that offer the specialty you have selected.

Community Health Center McKinney - http://www.chc-mckinney.com

EPIC Medical Clinic - https://epicmedicalclinic.org
Patient Information
Patient Name*

First NameLast Name
Patient Email *
example@example.com
Patient Phone Number*

Area CodePhone Number
Insurance Type*

NoneCHIPMedicaidMedicareOther
Reason for the referral / Additional information.*
Referring Clinic/Provider Information
Provider/Clinic Admin Contact

First NameLast Name
Provider/Clinic Email Address
example@example.com
Provider/Clinic Phone Number

Area CodePhone Number
The information contained in this form may be privileged and/or confidential, and protected from disclosure, and no waiver of any attorney-client, work product, or other privilege is intended.
Should be Empty:

Patient Information

Referring Clinic/Provider Information