Refer a Patient

Fill out the form below to refer someone.

Refer a patient to MindWell Urgent Care
Looking to refer someone? Fill out this form to start the process

Referral Source *

Healthcare Professional

Education Professional

Personal Relationship

Other

Referrer Name

First Name *

Last Name *

Name of Practice or Organization? *

Phone of Referrer? *

Referrer Email *

example@example.com

Patient Demographics

Patient Legal Name

First *

Last *

Patient Email *

example@example.com

Patient Phone *

Reason for Referral: *

Useful Links

(P) 214-247-6568
(F) 817-242-3174