Clinician Referral Form

Freddie’s team of clinicians provide patients with affirming and evidence-driven care, without judgement. Please complete this form to submit your patient referral directly to Freddie's compassionate team.
Section A: Patient Information
Referral Program*

HIV Prevention (PrEP)HIV+ Treatment
Patient's First Name*
Patient's Preferred Name
Patient's Last Name*
Patient's Email Address*
example@example.com
Patient's Date of Birth

MonthDayYear
Date
Section B: Referring Provider Information
Your First Name*
Your Last Name*
Your Email Address*
example@example.com
Once you submit this form, Freddie will reach out to the referred patient within 72 business hours.
Should be Empty:

Section A: Patient Information