Urgent Care Referral Form Important: This appointment is a telehealth visit focused on pain and musculoskeletal conditions. During the visit, the care team may provide assessment, education, and recommendations, and may advise in-person evaluation or referral when appropriate. This service does not provide emergency care and is not a general urgent care clinic. For emergencies, call 911 or go to the nearest emergency department.*I understandPATIENT INFORMATIONPatient NameFirstLastPhoneDate of BirthEmail*Date of AccidentCHECK ALL THAT APPLYAccident Occurred Within the Last 72 HoursPatient Has Not Started Medical CareRisk of Gap in Treatment (Weekend/Holiday Delays)Moderate to Severe Symptoms, Such As:Intense Sharp PainHeadaches or Suspected Concussion / Traumatic Brain Injury Numbness, Weakness, or TinglingReferring Provider Explains Urgency ClearlyPreferred Appointment Time (If Any)FOR THIS CAR ACCIDENT, I HAVE ALREADY BEEN TREATED AT:No TreatmentHospital ERUrgent CareChiropractorOtherName of Treating Facility(We will be Requesting Medical Records)I have Received Xray, MRI, CT, etc After the Date of InjuryName of Diagnostic Imaging FacilityTHIS IS AN URGENT CARE AND TELEHEALTH VISIT BECAUSEI had a recent Motor Vehicle AccidentI Don't have Health InsuranceI Don't have TransportationMy Wait Time is too Long For an Appointment at My PCPAre You Represented by an Attorney?YesI have not hired an attorneyIf yes, Name of The AttorneyAttorney Phone NumberSymptoms: Please Explain Your SymptomsThis appointment will take place virtually via Zoom. Do you have access to a device such as a smartphone, tablet, or computer that can support a virtual visit?YesNoDo you need an Interpreter? If so, What Language?SendThis field should be left blank
