Community Individual/Patient Referral Form
FOR PROFESSIONAL REFERRALS ONLY
Referring Professional Information
Please complete the following information about the professional/provider making the referral
Name of Referring Clinic or Organization
*
Referring Professional's Name
*
First Name
Last Name
Have you Referred a patient to EFGC in the past using this form
Yes, I have.
No, this is my first time using this form.
Unsure
Professional's Role / Title
*
Professional's Email Address
*
example@example.com
Professional's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Community Individual/ Patient Information
Community Individual/ Patient Name
*
First Name
Last Name
Community Individual/ Patient's Home Zip Code
*
Community Individual/ Patient's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Community Individual/ Patient's Email Address
example@example.com
Community Individual/ Patient's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Seizure Type (check all that apply)
*
Generalized Tonic Clonic
Absence
Focal Impaired Awareness
Focal Non-Impaired Awareness
Myoclonic
Atonic
Unknown
Other
Community Individual/ Patient's Preferred Language
*
Is the Community Individual/ Patient a Minor (under the age of 18)?
*
Yes
No
Back
Next
Caregiver Information
Caregiver Name
First Name
Last Name
Caregiver's Relationship to Patient
Caregiver Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Caregiver Email Address
example@example.com
Caregiver's Preferred Language
Back
Next
Please provide a brief overview of Community Individual/ Patient needs.
Authorization
*
By clicking this box, I confirm that I have discussed this referral with the Community Individual/ Patient and/or caregiver and have obtained their consent to be a part of the Client Services Department at the Epilepsy Foundation of Greater Chicago. The Community Individual/ Patient and/or caregiver has consented to be contacted by the Epilepsy Foundation of Greater Chicago.
Submit
Submit Registration
Should be Empty: