Refer a patient to the Gateway Down Syndrome Association
Please include the following information listed below to refer your patient with Down syndrome to the Gateway Down Syndrome Association (formerly Down Syndrome Association of Greater St. Louis) using our HIPAA-compliant form. The family can expect that a staff member will reach out to them within 2 weeks. We serve families who live within a 150 mile radius of St. Louis.
Name of Individual with Down syndrome
First Name
Last Name
Address of Individual with Down syndrome
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DOB of Individual with Down syndrome
-
Month
-
Day
Year
Date
Gender of Individual with Down syndrome
Female
Male
Parent/Caregiver Name
First Name
Last Name
Relationship to Individual with Down syndrome
Same address as above
Parent/Caregiver Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Caregiver Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Caregiver E-mail Address
example@example.com
Referring Physician Name
First Name
Last Name
Specialty
Please Select
Internist
Family Medicine
Pediatrician
Cardiology
Dermatology
Endocrinology
Gastroenterology
Genetics
Neonatology
Neurology
OB/Gyn
Oncology
Ophthalmology
Orthopedics
Otolaryngology
Podiatry
Psychiatry
Psychology
Sleep Medicine
Urology
Other
Other Specialty Not Listed
Referring Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referring Physician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Physician Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Physician Additional Notes or Comments (optional)
I certify that the individual listed above has a diagnosis of Down syndrome and subsequent intellectual disability. The caregiver consents to receiving information from the Gateway Down Syndrome Association.
Signature (Physician, Nurse Practitioner, Psychologist or LCSW)
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