Refer a client.

Complete the form below and we'll email a copy of the finished referral to you and to our intake team. Fields marked * are required.

Prefer to fill out the PDF yourself? Download the blank form

Referring attorney & law firm

Attorney name *

Law firm name *

Attorney phone *

Attorney email *

Your copy of the completed referral is sent here.

Referral Contact Name at Renuvia Health *

Case manager

Optional — who we should coordinate scheduling with.

Name

Phone

Client / patient information

Client full name *

Date of birth

Client phone *

Client email

Client address — street

City

State

ZIP

Gender

MaleFemale

Incident & injuries

Date of loss / incident *

Preferred clinic / location

Type of incident

Motor Vehicle AccidentCommercial VehicleSlip & FallWorkplace InjuryOther

Body regions / injuries involved *

This is a single line on the PDF — add longer detail in Referral Notes below.0/180 characters

Letter of Protection (LOP)

Policy limit

Services requested

Discseel EvaluationIV Exosome TherapyOther

Records & notes

Prior imaging / medical records on file?

YesNo

Referral notes

Treatment history, ER visits, pending imaging, scheduling constraints.

Authorization

I confirm that I am the referring attorney (or an authorized representative of the firm) and that I am authorized to share this referral information with Renuvia Health for the purpose of care coordination. *

Authorized signature *

Type your full name as your signature.

Date *

A completed PDF copy is emailed to you and to our intake team.

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