Refer a Patient

Refer a patient to Fountain Health using the form below. Our team will reach out directly to coordinate next steps and ensure continuity of care.

Fields marked * are required.

Referring Provider Information

Provider Full Name

Practice / Clinic Name (optional)

Provider Email

Patient Full Name

Patient Phone Number

Patient Email (optional)

I have informed the patient about this referral, and they are aware that Fountain Health may contact them.

Questions about a referral? Call (917) 886-7376. See our Privacy Policy for how we handle patient information.