Legion Psychiatry Referral Form
This brief form is used to notify the Legion team of a patient who needs care. Our operations team will typically contact the patient via email + phone in under 1 hour during business hours for scheduling. For more information about the clinical conditions we treat and the insurances we accept, please refer to our website: www.legionhealth.com
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient Email
*
example@example.com
Patient Phone Number
*
Please enter a valid phone number.
Referring Provider Name
*
First Name
Last Name
Referring Provider Organization
*
What organization is the patient being referred from?
Referring Provider Email
*
example@example.com
Referring Provider Phone Number
*
Please enter a valid phone number.
Referring Provider Fax Number
*
Please enter a valid fax number.
Referral Note
If possible, please use this field to provide some quick information about the patient. Clinical information (reason for referral, symptoms, severity, past or current medications), insurance details, and/or social history are especially welcome.
Submit
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