REMEDYPSYCHIATRY Email Marketing -

Referral Form

Please enter the patient's information using this secure form.

Please view Remedy Psychiatry's Privacy Policy for information about how information is collected and used.

Patient Information

Patient First Name*

Patient Last Name*

Patient Phone*

Patient Email*

Reason for Referral*

Provider Information

Referring Provider First Name*

Referring Provider Last Name*

Referring Provider Phone*

Referring Provider Email*

NPI Number*

By submitting this referral, you are formally acknowledging that the information provided herein is, to the best of your knowledge, entirely accurate. Furthermore, you are representing yourself as a healthcare provider or representative of a healthcare entity legally authorized to treat the aforementioned patient, and that dissemination of any patient health information from Remedy Psychiatry to you or the entity you represent is being requested for the sole purpose of rendering future care to the referred patient.