Continuing Education Courses - Loma Linda University Medical Center

International Patient Referral Form
If you wish to schedule a medical appointment, please complete the following form. Please note, the boxes with an (*) are required fields and must be completed. We know that health information about you is personal, and we are committed to protecting the privacy of your information. Your information is confidential and will only be seen by the International Patient Services Department and other appropriate medical personnel.

Please note: All emailed Patient Referral Forms will receive a response within 24-hours excluding weekends and holidays. The International Patient Services Department is open Monday through Friday from 07:30 a.m. to 6:00 p.m. PST.

Telephone: +1 909 558 3422
Fax: +1 909 558 3321

Your Information
Who Recommended Our Services To You?: Relative-acquaintance-friend
Physician
Embassy or government
Self (website or services research)
Other
First Name:*
Last Name:*
Gender:*
Date Of Birth:*   
Street Address:*
Street Address 2:
City:*
State:
Zip:
Country:
Daytime Phone:*
Preferred Phone:*
Home Fax:
Office Fax:*
Email Address:*
Contact's Name (if different from patient):
Contact Phone Number:*
Paitent's Diagnosis Information:*
Weight:*
Height:*
Allergies:* Yes No Not sure
If yes, please specify:
Previous Treatments Received: Radiation
Chemotherapy
Previous Surgery
If yes, please specify:
If you have had previous surgeries list details:
Method Of Payment:* Self pay cash-credt card-traveler checks-wire
International insurance-must be LLUMC contracted
Government or embassy sponsored
Comments for nurse intake or financial coordinator: