Patient Intake Referral

Submit a new patient referral to Bright Bridge

Patient Information

First Name *

Last Name *

Date of Birth *

Date of Injury

Contact Details

Mobile Phone *

Address

City

State

Zip Code *

Referring Law Firm

Documents (optional)

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Notes (optional)

Terms & Conditions

By submitting this intake or referral form, the undersigned agrees to the following: No-Show and Cancellation Policy: A "No-Show" occurs when a patient fails to attend a scheduled appointment without notification at least two (2) business days in advance. - First No-Show: $75.00 fee - Second No-Show: $75.00 fee - Third No-Show: Case termination and discontinuation of services No-Show fees must be paid in full before any future appointment may be scheduled. Case Restrictions: - Bright Bridge does not accept malpractice cases. Consent to Communications" - Consent is given for contact via telephone, email, text message, or electronic means for appointment and administrative purposes. Communication methods are not fully secure, and associated risks are accepted. Financial Responsibility: - The patient is fully responsible for all fees and charges for services rendered, including No-Show fees. Payment is expected at the time of service or as invoiced. Bright Bridge does not bill insurance carriers. HIPAA Acknowledgment: - Acknowledgment of receipt of or access to the Notice of Privacy Practices. Consent to Treatment: - Authorization is given for examinations, diagnostics, and treatment as deemed appropriate. Governing Law: - Governed by Texas law. Terms may be updated periodically.

I have read and agree to the above terms and conditions.

🔒This form collects protected health information (PHI). By submitting, you confirm that you are authorized to share this information and that it will be handled in accordance with HIPAA regulations.