Your partners in health care
To refer your patient to Fountain Health, please submit the secure form below. After you submit this form, a member of our clinical team will contact the patient to schedule an appointment and assist with registration if needed.
To refer a patient, please complete the following form and upload any relevant patient documents so that we may prioritize appointments or fax or email all relevant information. (Fax: 232-2029 | Email: email@example.com)
Suggested documents to assist in assessment include:
lab results (past relevant)
other specialists' information
names of other specialists and healthcare providers