Once you submit the referral, our team will review the information and reach out to the patient directly to discuss next steps and help them get started.

Please note: Do not send medical records or other medical documents through this form. Our team will let you know if any records or additional information are needed and how to securely provide them.

Referrer First Name *

Referrer Last Name *

Referrer Phone *

Referrer Email *

Referrer Type *

Referrer Message

Patient's first name *

Patient's last name *

Patient's phone *

Patient's email *

Reason For referral

Patient Consent

I confirm that the patient has agreed to be contacted by HealthStrategix regarding this referral.

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HealthStrategix

120 Academy St
Fort Mill, SC 29715

Phone: (980) 414-6350

Email: [email protected]