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Step 1: Stay Away From Design. Step 2: Use Clear Fonts. Step 3: Create Several Sections. Step 4: Make It Straightforward. Step 5: Don't Forget Your Signature.
A referral form is different than an opt-in form or survery. It is a form meant to refer visitors to companies that can provide them with what they are looking for. When your visitor fills out the referral form and clicks on the 'Submit' button, they are shown the advertiser's contact information.
The following information must be included on the Referral Authorization Form: Member name and ID number. Provider name. Diagnosis.
Up to date and correct patient information. Relevant medical history. Current medications and any allergies. Your details as the referring doctor.