Facility/Home Health Telemedicine Referral Form

Facility/Home Health Telemedicine Referral Form

Urgent Care/Dermatology/Wound Care
At Unified Health, we provide comprehensive healthcare services, including facility-based care, personalized home health services, and telemedicine consultations. Our commitment to excellence ensures that patients receive compassionate, effective, and convenient care tailored to their unique needs.
Facility Name
Diagnosis/Medical Condition
Reason For Consult
Contact Name
Contact Phone
Upload Demographic Facesheet or Fill out information below
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Patient Name
Full Name
SSN
Date of Birth

MonthDayYear
Date
Phone
Please enter a valid phone number.
Gender at Birth

MaleFemale
Identifying Gender

MaleFemaleNon-Binary
Address

Street Address

Street Address Line 2

CityState

Zip Code
Attach Copy of ID and Insurance ID

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Should be Empty: