Referral Form (for providers only)We welcome referrals from other health practitioners. Please complete the form below to refer a patient. Patient consent * I attest that patient has provided authorization for information in this referral to be submitted to Honest Health & Wellness. Yes Patient Name * First Name Last Name Patient Phone Number * (###) ### #### Name of Provider * Provider NPI # * Name of individual submitting request (if other than provider) Provider Email Address * Provider Phone Number * (###) ### #### Reason for referral (include ICD-10 codes) * Additional information about this referral Thank you! Your message has been sent.
