Health Care Provider Referral
Please fill out the information below to refer your patient to EFNE's programs and services. Once referral is received an EFNE staff member will reach out to person living with Epilepsy.
Referer's Name
*
First Name
Last Name
Referer's Institution
*
Please Select
Baystate Medical Center
Beth Israel Deaconess Medical Center (BIDMC)
Boston Children's Hospital (BCH)
Boston Medical Center
Brigham and Women's Hospital
Dartmouth Hitchcock Medical Center (DHMC)
Harvard Vanguard Medical Associates Cambridge
Hasbro Children's Hospital
Lahey Clinic
Maine Medical Center
Massachusetts General Hospital (MGH)
Memorial Hospital -Maine Health
Newton - Wellesley Hospital
Northern Lighth Eastern Maine Medical Center
Rhode Island Hospital
Tufts Medical Center
UMass Memorial Medical Center
University of Vermont Medical Center (UVM)
Kent County Memorial Hospital - Warwick RI
Wentworth-Douglas Hospital
Other
Referer's Institution (please enter the full name of your institution)
*
Eg. Massachusetts General Hospital
Referrer's Phone Number
Please enter the best number to reach you at.
Referrer's Email
example@example.com
Did the person living with epilepsy give verbal permission for you to give their name, email address and/or phone numbers, and patient information below to Epilepsy Foundation New England so that a program staff member can contact the person or their family member about available services and educational opportunities?
*
Yes
No
Please initial if the above is True
Did the person living with epilepsy give verbal permission for Epilepsy Foundation New England to talk with the Referrer about services Epilepsy Foundation New England provides?
*
Yes
No
Please initial if the above is True
Initial Referral
Yes
No
Name of Person living with Epilepsy
*
First Name
Last Name
Primary Epilepsy Connection
Please Select
I Have Epilepsy
Who do we reach out to
*
Person living with Epilepsy
Parent/ Caretaker
Caretaker's Name
First Name
Last Name
PWE E-Mail
example@example.com
PWE Mobile Number
Parent/Caretakers E-Mail
example@example.com
Parent/Caretakers Mobile Number
Any Notes You Would Like to Share...
Record Type
*
Please Select
Resource Rooms
Please verify that you are human
*
Submit Application
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