Recommend a Provider

Use this form to send information about a health center to someone else. We will also send them information about free birth control programs in Illinois and patient rights.

If you are not sure which provider you’d like to recommend, use our Find a Provider search tool.

Connect2Care/Referral Form
Enter your information.
Name
Name
First
Last
*so that we can let you know when the referral has been completed

Enter the recipient's information.

Their Name
Their Name
First
Last

Select a Provider Location

You can view providers by location in the map below, or search by location using our health center search.

If you want to see more information about a location, click on the pin and then click on the provider name in the pop-up window.

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Consent
Formulario Connect2Care

Ingrese su informacion.

Nombre de la persona que remite:
Nombre de la persona que remite:
Nombre
Apellido
* Para poder informarte cuando se haya completado la remisión

Ingrese la información del paciente.

Nombre del paciente/cliente*
Nombre del paciente/cliente*
Nombre
Apellido

Seleccione centro de salud para referencia.

Seleccione centros de salud por nombre. Para encontrar el centro de salud más cercano a su paciente/cliente, utilice nuestro buscador de centros de salud.

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Consent