Protera Health Referral Form

Protera Health Referral

To refer a member or patient to the Protera Health virtual musculoskeletal program (orthopedic clinician, physical therapy, health coaching, and care navigation), please fill out this secure form.
Who is submitting this referral?
Name of member/patient

First NameLast Name
Member/Patient's Health Insurance Plan
Date of birth

MonthDayYear
Date
Preferred email
Preferred Phone
Please enter a valid phone number.Format: (000) 000-0000.
Preferred time to contact
Preferred day to contact
Referred by:

Please enter your information below
Your Name

First NameLast Name
Your Email
example@example.com
What is referral for?
Diagnosis/Condition
Referring Provider Name

First NameLast Name
Referring Provider Email
Referring Practice Name
Signature
Notes
By submitting this referral, I confirm that the patient/member has agreed to be contacted by Protera Health regarding their care, including outreach by phone, text message, email, and mail. Message and data rates may apply for text messages, and the patient/member may opt out of communications at any time
By submitting this form, I understand that all clinical and physical therapy services will be provided by Protera Health Medical Group, P.C., which is an outpatient telemedicine-based provider.
Should be Empty:

Protera Health Referral