Refer a Client | Total Medical

Refer a client.

Complete the form below and we'll email a copy of the finished referral to you and to our intake team. Fields marked * are required.

Prefer to fill out the PDF yourself? Download the blank form

Referring attorney & law firm

Attorney name *

Law firm name *

Attorney phone *

Attorney email *Your copy of the completed referral is sent here.

Referral Contact Name at Total Medical *

Case manager

Optional — who we should coordinate scheduling with.

Name

Phone

Client / patient information

Client full name *

Date of birth

Client phone *

Client email

Client address (street, city, state, ZIP)

Gender

Male

Female

Incident & injuries

Date of loss / incident *

Preferred clinic / location

Type of incident

Motor Vehicle Accident

Commercial Vehicle

Slip & Fall

Workplace Injury

Other

Body regions / injuries involved *0/180 characters. This is a single line on the PDF — add longer detail in Referral Notes below.

Letter of Protection (LOP)

Policy limit

Services requested

Discseel Evaluation

IV Exosome Therapy

Other

Records & notes

Prior imaging / medical records on file?

Yes

Referral notesTreatment history, ER visits, pending imaging, scheduling constraints.

Authorization

I confirm that I am the referring attorney (or an authorized representative of the firm) and that I am authorized to share this referral information with Total Medical for the purpose of care coordination. *

Authorized signature *Type your full name as your signature.

Date *

A completed PDF copy is emailed to you and to our intake team.

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