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PRESTIGE COLLECTION SERVICES
PROVIDER REFERRAL FORM
Mobile Phlebotomy • Maternal Heart Health Support • In-Home Laboratory Services
Thank you for referring your patient to Prestige Collection Services. Please complete the information below and a member of our team will contact the patient within 24-48 business hours.
REFERRING PROVIDER INFORMATION
Provider Name
*
Practice Name
*
Specialty
*
Office Contact Person
*
Phone Number
*
-
Area Code
Phone Number
Fax Number
Email Address
*
example@example.com
Date of Referral
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PATIENT INFORMATION
Patient Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Email Address
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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City
*
State
*
Zip Code
*
Preferred Contact Method
Phone
Text
Email
PATIENT STATUS
Select all that apply:
*
Pregnant
Postpartum
High-Risk Pregnancy
History of Preeclampsia
History of Hypertension
Maternal Cardiac Concerns
Difficulty Attending Appointments
Transportation Barriers
Homebound
Routine Laboratory Services
Other
REQUESTED SERVICES
*
Mobile Blood Draw / Specimen Collection
Routine Laboratory Collection
Prenatal Laboratory Collection
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Postpartum Laboratory Collection
Blood Pressure Monitoring
Maternal Heart Health Support
Home Visit Coordination
Provider Requested Follow-Up
Other
LAB ORDER INFORMATION
Will laboratory orders be provided?
*
Yes - Attached
Yes - Will Be Sent Separately
No
Upload Laboratory Order/Requisition
*
Upload
Cancel
of
Upload Supporting Documents (Optional)
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of
SPECIAL INSTRUCTIONS
Please include any scheduling requirements, mobility concerns, language preferences, or clinical notes:
PATIENT CONSENT
I confirm that the patient has been informed of this referral and has consented to being contacted by Prestige Collection Services.
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WHAT HAPPENS NEXT?
Referral is reviewed.
Patient is contacted within 24-48 business hours.
Appointment is scheduled.
Services are completed in the patient's home.
Coordination is maintained with the referring provider as appropriate.
PRESTIGE COLLECTION SERVICES
Adraia Virgilio, LPN
Serving Henry County and the Greater Atlanta Metro Area
Phone: ________
Email: ________
Website: ________
Instagram: ________
"Bringing convenient healthcare access directly to your patients."
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