ChristCare Wellness Center

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

Date Submitted:

Referral #:

Patient Referral Form

Referral Instructions: Please complete this referral form and fax it to (978) 736-3011 or (978) 588-9569. Supporting documentation, such as recent progress notes, medication lists, laboratory results, or other relevant clinical records, may be included to facilitate timely coordination of care. For referral questions, call ChristCare Wellness Center at (978) 775-2067.

1. Referring Provider Information

Provider / Organization Name

Referring Provider Name

Phone Number

Fax Number

Email Address

2. Patient Information

Patient Full Name

Date of Birth

Phone Number

Email Address

Preferred Language

3. Referral Details

Reason for Referral (check all that apply)

Primary Care Services Chronic Disease Management Hypertension Management Diabetes Management Preventive Care & Wellness Visits Mental Health Services Medication Management Weight Management Women's Health Services Adult Day Health Services Other

Other Referral Reason

Diagnosis / Relevant Medical Conditions

Current Medications (Optional)

4. Insurance Information (If Available)

Insurance Provider

Member ID

5. Additional Notes

Additional Notes

6. Authorization

I confirm that the patient has consented to this referral and the sharing of relevant healthcare information for coordination of care.

Referring Provider Signature

Date

🏠 Bring to Office 42 Lancaster St, Unit 2
Leominster, MA 01453
Mon-Thu: 9:00 AM - 5:00 PM
Fri: 9:00 AM - 2:00 PM
Sat-Sun: Closed

📠 Fax Numbers Fax completed form to:
(978) 736-3011
(978) 588-9569

📞 Questions? Call the practice:
(978) 775-2067
mail@christcarewellnesscenter.com