Patient Referral Form

Please complete the following information.  By completing and submitting this form, you represent that you are authorized to share the information below, including the patient's medical information, with LLS. Upon receipt, an LLS Information Specialist will reach out to the patient and send resource information.  Patient information provided will remain confidential, however, names will be added to our Patient & Community Outreach mailing list.  
For any questions, contact the Information Resource Center at 1-800-955-4572.   

With which race(s) do you identify? (select all that apply) *
Do you identify as Hispanic, Latino or Spanish Origin *
Have you ever served on active duty in the U.S. Armed Forces, Military Reserves, or National Guard? *

Healthcare Professional making the referral