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Refer a Patient

You can either fill out and submit the form below or download and then send the filled out form to our clinic via email or fax. 

Patient Referral Form

Patient Information

Patient Date of Birth
Month
Day
Year

What services and/or conditions is the patient being referred for?

Referrer Information

You may upload a maximum of three documents/files.

Important Note for Providers

 

At Optima Kidney Care, I recognize the significant wait times many patients face when referred for nephrology evaluation.

 

If you have an urgent referral that requires priority scheduling, please contact me directly at referrals@optimakidney.com. This is a HIPAA-compliant email address dedicated to provider communication.

Please include “Urgent Referral” in the subject line and provide any pertinent details that would help me understand the clinical urgency. I will make every effort to accommodate these patients as quickly as possible and ensure they are seen in a timely manner.

If you have any questions, or if you would like to speak with me directly regarding a patient, please feel free to call or text me at (503) 749-9939.

Fax

503-714-9620

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