Clinical Referral Intake • Pristine

OB-GYN Patient Referral Form

Submit clinical demographics, OB-GYN specialty requests, and diagnostic records directly to our intake team.

OB-GYN Referral Form

* Please note that this appointment is tentative and will not be confirmed until our team has reached out to you. In partnership with Pristine OB-GYN.

1. Select Appointment Type *

2. Service or Appointment For *

Please choose the clinical service or type of appointment required.

3. Referring Facility *

Referral Facility Phone *

Referral Facility Fax

4. Person Making Referral *

5. Client Full Name *

6. Date of Birth *

Date

7. Contact Number *

Please enter a valid phone number.

8. Secondary Phone Number

9. Email Address

10. Please select payment/insurance type *:

11. Please select one of the following insurances *:

(ONLY THESE INSURANCES ARE ACCEPTED)

12. Insurance ID (Include any prefixes):

13. Select Clinic Location *:

14. Select an available appointment date *:Mon – Fri: 9:00 AM – 5:00 PM (Open select Saturdays also)

July 2026

SUNMONTUEWEDTHUFRISAT

Open selected SaturdaysAvailable Days

Date: None (No Date Selected)

Select Clinic Location

Please select a clinic location first to view availability.

Timezone:America/Chicago (Central Time)

Optional Attachments (Medical Records, Demographics, Ultrasounds)

Upload any relevant documents to expedite clinical processing. Max file size: 50MB.

Demographics SheetPatient demographics, face sheets or registry details.

Upload Sheet

Ultrasound Images / ReportsOB-GYN scans, ultrasound printouts or reports.

Upload Image

Clinical Notes & RecordsPast medical history, lab results or consult sheets.

Upload Notes

15. How will you send the referral / Discharge?

Fax (281-206-4487)Email (schedule@pristines.org)

Declaration: The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for the use of the person(s) named herein.

Accept the declaration: I accept *

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