HCP Referral 2

Physician Name
Physician Location
Ped/PCP Name
Ped/PCP Location
Neuro Name
Neuro Location
All HCP Names
All HCP Locations
Language
Submitter
I am:

A patient 18 years or older A caregiver of a patient
Referral

Yes
Referred

Physician Allied Health
your or patient's
What is {yourOr} name? *
First name
What is {yourOr} name? *
Last name
Patient's full name
Patient's full name URL
What is your name? *
First name
Last name *
Last name
Caregiver's full name
Caregiver's full name URL
you or patient's name
You or Patient's name
are or is
Were or Was
have or has
Have or Has
Do or Does
do or does
your or patient's name's
Your or patient's name's
my or patient's name's
qualify or qualifies
Need help? Call us at 1-877-584-8995 or email us at registration@ambitinc.com.

Preventing hover text automatically
What is the best email and phone number to reach you?
Email *
example@example.com
Mobile phone number *
We use your phone number to contact you regarding AmbitCare services only. We do not sell or disclose your phone number and other personal information collected in the assessment to third parties.
Please check the box below to proceed. *

I agree to AmbitCare's Privacy Policy and Terms & Conditions.
To review, click here for our Privacy Policy and here for our Terms & Conditions. * ⓘ
PP and T&C

I agree
Need help? Call us at 1-877-584-8995 or email us at registration@ambitinc.com.

Thank you for submitting your contact information! Please fill out a few more questions in preparation for genetic services.
Current Date

Month Day Year
Date
Hour Minutes AM/PM Option
1 year ago from today

Month Day Year
Date
What is {yourOr251} date of birth? *

Month Day Year
Date
DOB-2
What is {yourOr251} gender? *
Age
UniqueID
Thank you for your interest in AmbitCare's services!

We are currently only offering services to those patients who are either 18 years or older or caregivers who are taking care of their loved ones. If you are under the age of 18 as a patient, please contact your legal guardian to help you fill out this assessment.
Need help? Call us at 1-877-584-8995 or email us at registration@ambitinc.com.

Approximately how many seizures of unknown cause {haveOr} {youOr} had to date?

No seizures of unknown cause 1 seizure of unknown cause 2 or more seizures of unknown cause I'm not sure if the patient is having seizures
#Seizures
Need help? Call us at 1-877-584-8995 or email us at registration@ambitinc.com.

What is your mailing address? *

Street Address

Street Address Line 2

City

Zip Code
Street Address

Street Address Line 2

State
Need help? Call us at 1-877-584-8995 or email us at registration@ambitinc.com.

Please agree to our Genetic Services Consent below.
Date

Month Day Year
Date
AmbitCare Genetic Services Consent

To receive genetic services and resources through Ambit RD, Inc. ("Ambit"), please confirm the following:
- If the patient is a dependent/child, I am the legal guardian authorized to provide consent on behalf of this dependent/child.
- I consent for Ambit to share my information with an independent genetic counseling provider to provide pre- and/or post-test genetic counseling.
- I give permission for Ambit and Ambit's genetic counseling provider to request and discuss healthcare records, and to share notes from genetic counseling and test results with my named physician(s).
- I consent for Ambit to receive a copy of my genetic counseling notes and test results.
- I give consent to Ambit to share de-identified data with Ambit's research partners, including academic research and healthcare companies. No identifiable information will be shared.
- I would like to proceed with a genetic test sponsored by AmbitCare.
Your name: {caregiversFull}

Patient's name: {patientsFull}

Date: {date}
AmbitCare Genetic Services Consent

To receive genetic services and resources through Ambit RD, Inc. ("Ambit"), please confirm the following:
- If the patient is a dependent/child, I am the legal guardian authorized to provide consent on behalf of this dependent/child.
- I consent for Ambit to share my information with an independent genetic counseling provider to provide pre- and/or post-test genetic counseling.
- I give permission for Ambit and Ambit's genetic counseling provider to request and discuss healthcare records, and to share notes from genetic counseling and test results with my named physician(s).
- I consent for Ambit to receive a copy of my genetic counseling notes and test results.
- I give consent to Ambit to share de-identified data with Ambit's research partners, including academic research and healthcare companies. No identifiable information will be shared.
- I would like to proceed with a genetic test sponsored by AmbitCare.
Your name: {patientsFull}

Date: {date}
*

I agree to AmbitCare’s Genetic Services Consent
Consent

I agree
I would like to proceed with the Epilepsy Panel (a genetic test) sponsored by AmbitCare
Test Consent

I agree
Need help? Call us at 1-877-584-8995 or email us at registration@ambitinc.com.

What is {yourOr251} race or ethnicity? Please select all that apply.

American Indian or Alaska Native Asian (including East Asian, South Asian or Southeast Asian) Black or African American Hispanic, Latinx, or Chicanx Middle Eastern or North African Native Hawaiian or Pacific Islander White Individuals reporting another race, ethnicity, or origin, not on this list or who prefer not to disclose their ethnicity
Ethnicity
4CommunicationsLog
Need help? Call us at 1-877-584-8995 or email us at registration@ambitinc.com.
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Thank you for your interest in AmbitCare's services!