New Referrals Form

Instructions for Email Field Entry
If a patient does not have an email address, please create a placeholder email using the following format:
[Patient's First Name Initial][Patient's Last Name] [email protected]
Examples:

• For Jane Doe: [email protected]

Important Notes:

• Use this format only if the patient has no personal email address.

• If the patient shares a phone number or email with another contact (e.g., a family member), ensure this unique placeholder email is used to avoid merging their contact record with others in the system.

• Double-check the spelling of the name to ensure accuracy.