Pure Health Medicine – Book Your Telemedicine Appointment

Patient Referral

We try to ensure providing you the services as quick as possible, for that kindly provide maximum information in the form below. However, if there is further information needed, you will be contacted on the number given below by you.

    First Name

    Middle Name

    Last Name

    Select Gender

    MaleFemale

    Address

    Date Of Birth *

    City

    State

    ZipCode

    Phone *

    Alternate Phone

    Email *

    Disciplines(Select All that Apply) *
    I understand that Pure Health Medicine only delivers care via Telehealth by a licensed medical professional.

    I accept

    Does the Patient attend School?

    YesNo

    Preferred Schedule

    Patient and/or guardian First Name *

    Patient and/or guardian Last Name

    Primary Diagnosis *

    Secondary Diagnosis

    Referral Information

    Person Making Referral

    Referral's Email

    Referral's Phone Number

    Referral's Fax Number

    How did you hear about us?

    MailerInternetSearchMarketing MaterialEventFacebook/ Social Media Staff MemberDoctor’s OfficeGovernment AgencyFriendWord of MouthOther

    Additional Information