ChristCare Wellness Center

42 Lancaster St, Unit 2 • Leominster, MA 01453
Phone: (978) 775-2067 • mail@christcarewellnesscenter.com

Date Submitted:

Referral #:

Patient Referral Form

1. Patient Information

Patient Full Name

Date of Birth

Phone (Primary)

Phone (Secondary / Cell)

Email Address

Street Address

City / State / ZIP

Gender

Male Female Other / Prefer Not to Say

Preferred Language

English Francais Kreyol Espanol

2. Insurance Information

Primary Insurance

Member / Policy ID

Secondary Insurance (if any)

Group Number

Insurance Phone Number

Policyholder Name (if different from patient)

3. Referring Provider Information

Referring Provider Name / Practice Name

NPI Number

Phone

Fax

Email (Optional)

Address

4. Reason for Referral

Primary Diagnosis / Concern

ICD-10 Code(s)

Type of Referral

New Patient — Primary Care Functional Wellness Chronic Disease Management Preventive Health Telehealth Follow-Up Other (specify below)

Clinical Notes / Additional Information

Urgency

Routine (within 30 days) Urgent (within 1 week) STAT (please call office)

5. Current Medications & Allergies

Current Medications (name, dose, frequency)

Known Allergies (medication, food, environmental)

6. Authorization & Signature

By signing below, I authorize ChristCare Wellness Center to share relevant medical information with the referring provider as needed to coordinate care, and I consent to the terms of this referral.

Patient Signature

Date

Referring Provider Signature

Date

🏠 Bring to Office 42 Lancaster St, Unit 2
Leominster, MA 01453
Mon–Fri: 9:00 AM – 5:00 PM

📠 Fax Fax completed form to:
(978) 000-0000
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📞 Questions? Call the practice:
(978) 775-2067
mail@christcarewellnesscenter.com