Refractions

Refer A Client

Menu

Referral Form

Newest Standing Orders

DOWNLOAD PDF

ROI - Guardian Pharmacy

DOWNLOAD PDF

If you wish to send us your information directly, instead of using the online form, please fax documents to 320-252-6278 or email them to jvener@refractions.us.com.

We will need information that gives us insight into the client’s current life situation to get started. This helps us determine whether they meet our criteria for care and if they may be a good fit for one of our facilities.

IRTS REFERRAL INFORMATION FORM

"*" indicates required fields

Contact Information

MM slash DD slash YYYY
Gender
Client Name*
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

Diagnoses

Type of Commit
Any current prescription sent over to our providing pharmacy with a 30-day supply

Benefits

Income Source(s):
Benefits Type

THE FOLLOWING INFORMATION WILL BE REQUIRED PRIOR TO INTAKE:

Please Select Completed Items

ADDITIONAL INFORMATION PERTINENT TO IRTS PLACEMENT

Please include support system, cultural considerations, etc.
Please type Client name or Legal Guardian/Authorized Person here.
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.