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Refer a Patient to Third Space Therapy
Thank you for referring your patient to Third Space Therapy. To help us provide the best possible care, please complete this referral form with your patient's contact information and insurance details. We'll reach out to schedule their first appointment within 12-24 hours.
Patient's Information
Patient's First Name
*
Patient's Last Name
*
Patient's Email Address
*
We need the patient's email to send them a link to our patient portal to
complete our intake & consent forms, and attend their tele-therapy session.
If the patient does not have an email address, please share the email of a parent, guardian, or caretaker who can coordinate the appointment on behalf of the patient.
We're unfortunately unable to accommodate patients without an email address at this time.
Patient's Phone Number
*
Patient's Date of Birth
*
Patient's Sex (as listed on insurance policy)
*
Patient's Sex (as listed on insurance policy)
Female
Male
Patient's Gender Identity
*
Patient's Gender Identity
Female
Male
Transgender Female
Transgender Male
Genderqueer
Prefer not to say
Other
Patient's State of Residence
*
Patient's State of Residence
Arizona
Colorado
Massachusetts
Virginia
Other
Patient's Reimbursement Type
*
Please select all that apply
e.g. dual-eligibility, secondary, replacement plans, etc.
Patient's Reimbursement Type
Medicaid
Medicare
Commercial/Private Insurance
TRICARE
Self-Pay
Other
Name of insurance plan
*
Please choose the exact plan that is listed on the patient's insurance card.
If you can't find the plan in the list below, please choose 'Other' at the end of the list.
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