Direct Referral Form

Direct Referral Form

The following patients are being referred for thermographic evaluation.

Patient Name(s)*

BTI Technician Name*

First NameLast Name
Comments
Referring Provider*

First NameLast Name
NPI*
Email*
example@example.com
By signing this referral, I acknowledge and agree that I am solely responsible for reviewing, interpreting, and discussing the thermographic report findings with the client, and for determining any clinical significance, recommendations, or follow-up within my scope of practice.
Signature of Physician or Tech uploading written referral*

Clear
Date*

MonthDayYear
Date
File Upload

Written referrals upload here only. All referral forms must have physician signature and NPI number.
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