Referral Request Form Please fill out the form below to request a referral from your doctor. You will be contacted when your referral has been sent to your chosen specialist, or if a consultation with your doctor is required.Patient Name(Required) First Last Date of Birth:(Required) DD slash MM slash YYYY Doctor's Name:(Required)Dr. David JaaDr. Ping JaaDr. Paul PaytonReferral Information(Required) Specialist Name and Contact information. Patient Email Address:(Required) Patient Phone(Required)Consent(Required) I agree to the privacy policy.I confirm I wish to communicate with Dr. Jaa's Medical Health via email/text and I understand that: It is my request to use email / text; Email / text is not a totally secure system for sending and receiving information; Any decision to use email / text communication will be documented in my clinical records; Emails may be printed and stored in my clinical records; Text communications may be documented in my clinical records; No emails - either sent by me or the staff member will be forwarded to anyone else with consent of any party; Any decision made by myself to stop the use of email / text will be respected upon written notice. Any resumption will therefore require a new Consent Form; Confidentiality will be respected by staff at all times. I am signing to confirm that I have understood the conditions as set out above and have been made aware of the associated risks with regards to data protection. Δ
