Client Referral Form
Give referring professionals a secure, simple way to send client information to your practice. Referrers can share client details, the reason for referral, preferred timing, payment information, and supporting documents in one HIPAA-compliant form. This helps reduce back-and-forth while keeping sensitive referral information private.
Form Template Preview
Submit this form to see what a completed submission looks like inside Hushmail:
Quick facts about this form
Who it's for:
- Healthcare practices
- Behavioral health providers
- Physical therapy clinics
- Chiropractic practices
- Massage therapy practices
- Dental practices
- Nutrition professionals
- Holistic care providers
- Other providers who accept professional referrals
Why use it:
- Give referral partners one secure way to send client information
- Collect the referral details you need in one submission
- Accept supporting documents securely
- Reduce follow-up for missing referral information
Where to use it:
- Add it to a referral page on your website
- Include the form link in your email signature
- Send the link when another provider asks how to refer a client
If your client skips a required field, the form will prompt them to fill it out. No more chasing after clients to fill out missing info.
Your client’s submission will live in Hushmail, where you can keep all submissions secure and organized in folders.
You can also download a PDF of the submission if you want to file a separate copy elsewhere, like your EHR.
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You give us the form(s) you’re currently using in your practice.
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You get a dedicated Customer Care rep to oversee the service and answer questions.
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You end up with custom secure web forms that are easy for your clients to fill out.
