Referral Form

We appreciate you for choosing Elle Cliniques HTC to serve your client's needs. The office will follow up with the client withing 48 hours of receiving this referral form and provide feedback as appropriate.

Provider's Name and Credentials

Agency's Name

Street Address

City

Region/State/Province

Postal / Zip code

Last Session with client

Referring Date

Client's First and Last Name

Client's Date of Bith

Policy/member ID #

Group ID #

Front view of your insurance card

Upload File

Back view of your insurance card

Upload File

Secondary insurance card front

Upload File

Secondary insurance card back

Upload File

Do you have anything to share with us?

Form Completed by:

Today's Date

For a smoother communication and collaboration, we are pleased to provider several avenues to reach us and to better coordinate client's care.

Sincerely,

Administrative,

Elle Cliniques HTC.

Info@ellecliniques.com. Phone: +1 (407) 377-7570, Fax: +1 (407) 377-7898