Thank you for taking the time to refer your client to Vidal Medical. To make the process more streamline we have created this simple questionnaire below. This will constitute as your referral and our team will be in touch to set up an appointment. Again, thank you for your referral and we look forward to working together.

The Vidal Medical Team

REFERRER INFO:

Referring Company/Affiliate *

Referred by who? *

Referrer's Email *

CLIENT INFO:

First Name *

Last Name *

DOB *

Gender *

Cell Phone *

Address

Street Address

City

State

Country

Postal code

Email *

DETAILS, GOALS & LABS

Please provide as much detail as you can so our collaborative medical care compliments your coach and client goals. You may enter N/A as well.

What would you like to refer to your client today? *

What have you tried so far and what was the result? *

Is there anything you have already discussed for us to provide? *

If they have recent labs. Please Upload here

Would you like to join your clients virtual meetings? *

Yes