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Please complete form

1. Referral's Full Name*

Referral's Organization/Practice*

Referral's Professional Title/Role*

Referral's Phone Number*

Referral's Email Address*

Preferred Contact Method*

Phone

2. Client's full name*

Client's Birthday*

Month

Day

Year

Client's Phone*

Client's Email*

Client's City and State*

Client's Preferred Method of Communication*

Phone

This is a checkbox.

3. Requested Services Select all that apply*

Wellness Strategy Consultation

Preventative Health & Chronic Wellness Support

Lymphedema Evaluation & Management Services

Manual Lymphatic Drainage

Integrative Wellness Services

Health Education

4. Reason for referral. Briefly describe the client's needs or requested services*

Preferred Service Location*

In-Person

Mobile Services (where available)

Virtual Consultation. (where available)

5. Has the client agreed to be contacted by True Life Medical regarding this referral?*

Yes

Client's Preferred Contact Time:*

Morning

Afternoon

Evening

Please obtain the client's permission before submitting their personal information. Do not include sensitive medical information unless it is necessary, authorized, and transmitted through an approved secure method.

Referral Confirmation *

I confirm that the information provided is accurate to the best of my knowledge.

I understand that submitting this form does not guarantee acceptance of the referral or availability of services

Referrer Name*

Date*

Month

Day

Year

What Happens after referral is submitted?

1. Referral Received: Our team reviews the submitted information

Client Outreach: We contact the client to discuss their needs and available services, provided appropiate permission has been obtained.

Service Coordination: We assist the client with scheduling and next steps.
Follow-Up: Referral partners may receive appropiate updates when authorized.

True Life Medical, LLC

Your Partner in Preventative Care and Wellness

Phone: 443-201-1503

Email: info@truelifemedical.org

Website: www.truelifemedical.org

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