Referral Form

Refer a Patient

Thank you for choosing Reliable Medical. If you would like to refer a patient, please fill out the referral form below. If you have any questions or would like to speak with our team, please contact us.

IMPORTANT! We do not use your phone number collected on this form for SMS messaging. This number will only be used to contact you via phone if you request that contact method.

Contact Information

* - Indicates required fields
Location*
Requester/Senders Information
Name
Relationship to Patient
Phone Number
Email
Patient Information
Patients First Name*
Patients Last Name*
Patient DOB*
Patient Phone Number*
Equipment Requested*
Insurance Name*
Policy Number/ID Number
Group Number
Phone Number from Back of Card
Patient Discharge Date
Order Notes
Physician Information
Physician Full Name
Physician NPI
Physician Phone
Physician Fax
Please upload Rx, Progress Notes, and Face Sheet:
control + click to add additional

Refer a Patient

Contact Information

Requester/Senders Information

Patient Information

Physician Information