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.

Patient's First Name *

Middle Initial

Patient's Last Name *

Street Address *

Apt.

City *

State *

Zip Code *

Phone Number *

Email Address [if you do not have an email address, please enter NoEmail@NoEmail.com] *

Patient's Date of Birth (MM/DD/YYYY) *

Patient's Date of Diagnosis (MM/DD/YYYY) *

If minor, Parent/Guardian First and Last Name:

Diagnosis (select one) *

Other Diagnosis:

With which race(s) do you identify? (select all that apply) *

Do you identify as Hispanic, Latino or Spanish Origin *

Yes

No

Prefer Not to Answer

Have you ever served on active duty in the U.S. Armed Forces, Military Reserves, or National Guard? *

Yes

No

Prefer Not to Answer

Primary Language Spoken *

Healthcare Professional making the referral

First Name *

Last Name *

Phone Number *

Institution *

Email Address *

Comments

Today's Date * +