Health Care Provider Referral

Health Care Provider Referral

Please fill out the information below to refer your patient to EFNE's programs and services. Once referral is received an EFNE staff member will reach out to person living with Epilepsy.
Referer's Name

First NameLast Name
Referer's Institution
Referer's Institution (please enter the full name of your institution)
Eg. Massachusetts General Hospital
Referrer's Phone Number
Please enter the best number to reach you at.Format: (000) 000-0000.
Referrer's Email
example@example.com
Referrer's Address

Street Address

Street Address Line 2

CityState

Zip Code
Did the person living with epilepsy give verbal permission for you to give their name, email address and/or phone numbers, and patient information below to Epilepsy Foundation New England so that a program staff member can contact the person or their family member about available services and educational opportunities?
Please initial if the above is True
Did the person living with epilepsy give verbal permission for Epilepsy Foundation New England to talk with the Referrer about services Epilepsy Foundation New England provides?
Please initial if the above is True
Initial Referral
Name of Person living with Epilepsy

First NameLast Name
Primary Epilepsy Connection
Who do we reach out to
Caretaker's Name

First NameLast Name
PWE E-Mail
example@example.com
PWE Mobile Number
Format: (000) 000-0000.
Parent/Caretakers E-Mail
example@example.com
Parent/Caretakers Mobile Number
Format: (000) 000-0000.
Any Notes You Would Like to Share...
Status
Record Type
Please verify that you are human
Should be Empty: