Lakeland Clinic Outpatient Referral Form

Referral Source Information
Organization Name * Required
Person Making Referral * Required
First Last
Office Contact Person * Required
First Last
Office Contact Phone * Required
Office Contact Fax
Office Contact Email
Patient Information
Legal Name of Patient * Required
First Last
Patient Date of Birth * Required
Parent/Guardian Name (if applicable)
First Last
Phone Number * Required
Email
Primary Insurance * Required
Insurance Subscriber Name * Required
First Last
Patient Referred To: Lakeland Clinic Psychiatric Consultation
Patient Authorization of Release of Information * Required
Patient has authorized this referral source to share this form with Pine Rest for the purpose of discussing and scheduling patient's appointment. An additional release of information will be required to discuss treatment.
What is the concern that you would like addressed: * Required
Please note that the following labs will need to be faxed to us prior to the appointment: CBC, CMP, UDS, TSH, Vitamin B12, Vitamin D. If labs are not received prior to the initial appointment, we will need to reschedule the appointment. Labs can be faxed to 877-242-6963.
Is Telehealth

Accredited by The Joint Commission. Accredited by the Commission on Accreditation of Rehabilitation Facilities.

Associate Member of the National Network of Depression Centers

Referral Source Information