GCF Referrals

Submit Your Referral to CIT Clinics
We are ready to support your clients quickly, efficiently and compassionately.

Please submit the information below so we can begin the patient onboarding process.
Information about you
Type of referral

Case ManagerClinician
Your Name*

First NameLast Name
Your Email*
example@example.com
Your Mobile Phone Number*
Please enter a valid phone number.
Company/Practice Name
Important information for CIT Clinics regarding this referral (optional)
Information about your Client/Patient
Patient Name

First NameLast Name
Patient Email
example@example.com
Patient Phone Number
Please enter a valid phone number.
Upload Patient Referral Form and/or Other Documentation

Cancelof
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Submit Your Referral to CIT Clinics