NV PAL Patient Information Form
Please complete this HIPAA-compliant form to tell us about your patient. Once you've submitted this form, a NV PAL representative will be in touch within the scheduled time/date you've requested below.
Referring Primary Care Physician (PCP) name:
Referring PCP call back number (prefer cell):
(PCP) Email
example@example.com
Patient Name (first / last):
Patient date of birth (mm/dd/yyyy):
Race:
Please Select
American Indian or Alaska native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Other
Ethnicity:
Please Select
Hispanic or latino
Not hispanic or latino
Sex:
Please Select
Female
Male
Other
Guardian name (first / last):
Guardian contact info (cell phone / email):
Reason for consult:
Please Select
Help with referrals/treatment recommendations
Diagnosis clarification
Medication advice
Follow up call on past PAL patient
Other (if "other," please specify in next section)
If "other" selected from question above, please specify reason for consult:
When would you like us to contact you?
ASAP
in 30 minutes
Other (if "other" please specify in next query)
Select call back time (weekday between 9am-5pm PST):
Submit
Should be Empty: