HCP Referral 1

Physician Location Initial
Language
Hi there! We are happy to be able to provide you and your healthcare provider with AmbitCare's free genetic services. We just have a few questions to get started. They should take no more than 5-10 minutes to complete.
We will be asking you a series of questions about you or your loved one's medical information so that we can best provide customized services to you. Your privacy is very important to us, and we make every effort to keep your and your loved one's information safe and secure. All this information will be encrypted and securely stored.
I am:*

A patient 18 years or olderA caregiver of a patient
Submitter
you see or the patient sees
you or the patient
your or the patient's
do or does
Any information you submit may be stored, reviewed, and analyzed by AmbitCare for purposes of connecting you with relevant resources. AmbitCare does not sell your personal identifiable information to others. Only your de-identified, summary data is shared with our research partners, such as academic researchers and healthcare companies, if you consent in an effort to advance treatment options.

Please note that AmbitCare provides this information for the benefit of the rare disease community. AmbitCare is not a medical provider nor a health care facility. AmbitCare can neither diagnose any disease or disorder nor endorse or recommend any specific medical treatments. Individuals must rely on the personal and individualized medical advice of their qualified health care professionals before seeking any information related to their particular diagnosis, cure, or treatment of a condition or disorder.

Need help? Call us at 1-877-584-8995 or email us at registration@ambitinc.com.
Please note that AmbitCare provides this information for the benefit of the rare disease community. AmbitCare is not a medical provider nor a health care facility. AmbitCare can neither diagnose any disease or disorder nor endorse or recommend any specific medical treatments. Individuals must rely on the personal and individualized medical advice of their qualified health care professionals before seeking any information related to their particular diagnosis, cure, or treatment of a condition or disorder.

Need help? Call us at 508-203-6891 or email us at registration@ambitinc.com.

We see that you are a referral from {physicianLocationInitial}.
What is the name of the provider at Texas Tech Physicians of El Paso Pediatrics {youSee} most often?*
What is the name of the provider at Intermountain Medical Group {youSee} most often?*
What is the name of the provider at Children's Neurological Specialties {youSee} most often?*
What is the name of the provider at Sunrise Pediatric Neurology {youSee} most often?*
What is the name of the provider at The Family Medicine Center {youSee} most often?*
What is the name of the provider at Ashe Pediatrics, PLLC {youSee} most often?*
What is the name of the provider at Crescent Neurology and Sleep {youSee} most often?*
What is the name of the provider at Pediatrix Neurology of Nevada {youSee} most often?*
What is the name of the provider at Valley Children's Healthcare {youSee} most often?*
What is the name of the provider at Beacon Medical Group {youSee} most often?*
What is the name of the provider at HighPoint Neurology Associates {youSee} most often?*
What is the name of the provider at Behavioral Pediatrics at Home {youSee} most often?*
What is the name of the provider at Mecklenburg Neurology {youSee} most often?*
What is the name of the provider at Pediatric Specialists at Elm Street {youSee} most often?*
Physician Name temp
Which physician at {physicianLocationInitial} {doOr} {youOr} see most often?*
What is the name of the physician who is treating {yourOr} symptoms? (e.g., "Dr. Elena Garcia." If you are unsure or do not want us to talk to your physician, type “N/A”.)*
Name of the physician’s practice or healthcare system and location (if you know one or both type them in, else if you are unsure of either please type “N/A”)*

Name of practice or healthcare system

Street Address Line 2

CityState

Zip Code
What is the name of {yourOr} pediatrician or primary care provider? (e.g., "Dr. Maria Li." If you are unsure or do not want us to talk to this physician, type “N/A”.)*
Name of the pediatrician or primary care provider’s practice (e.g., "Acme Pediatrics." If you didn't name a pediatrician/PCP above, type "N/A.")*
What is the name of {yourOr} neurologist? (e.g., "Dr. Ivan Sidorov." If you do not have one, or if you do not want us to talk to this physician, type “N/A”.)*
Name of the neurologist’s practice (e.g., "Park Neurology." If you did not name a neurologist or are unsure of the practice name, please type “N/A.”)*
Physician Name
Physician Location
Ped/PCP Name
Ped/PCP Location
Neuro Name
Neuro Location
Referral

Yes
Referred

PhysicianAllied Health
Need help? Call us at 508-203-6891 or email us at registration@ambitinc.com.
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Hi there! We are happy to be able to provide you and your healthcare provider with AmbitCare's free genetic services. We just have a few questions to get started. They should take no more than 5-10 minutes to complete.