Referral Form

Please enter the patient's information using this secure form. Please view Remedy Psychiatry's Privacy Policy for information about how information is collected and used.

* Patient first name

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* Patient last name

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* Phone number

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* Email

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* Referring provider first name

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* Referring provider last name

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* Speciality

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* Referring provider phone number

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* Referring provider email

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* NPI number

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* Patient has given permission to be contacted

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Remedy Psychiatry | 200 S Barrington Ave PO Box 492124 | Los Angeles, CA 90049 US

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