For patients

Your starting point for care.

Tell us how we can help with in-home evaluations, testing, or coordination with your primary care provider. Complete this self-referral, review it, and print or save a PDF.

Complete → Review → Save PDF → EmailYour entries stay in this page. The website does not save or submit them. After saving your PDF, you can open an email draft and attach it yourself. Call 951-368-0428 to confirm the recipient address and approved email method before sending health information.

This form is not monitored for urgent requests. For a medical emergency, call 911. Closing or refreshing this page discards your entries.

1. Patient details

Fields marked * are required. Email is required only when you choose email as your preferred contact method.

First name *Last name *Date of birth *Street address *City *State / territory *ZIP / postal code *Phone *Alternate phoneEmailPreferred contact method *Best time to contact youMay Apogee leave a voicemail? *Preferred languageAccessibility or communication needs (optional)

2. How can we help?

Share a brief summary. Do not include Social Security numbers, insurance member numbers, or detailed medical records. If you do not have a PCP, leave those fields blank. Services depend on review and availability.

What would you like to discuss? *Brief reason for your request *Primary care provider (PCP) namePCP practice / clinicPCP phonePrimary insurance (optional)Additional information (optional)

3. Person completing this form

If completing this for someone else, provide your name, relationship, and phone number. Apogee may need to confirm your authority before discussing care.

I am completing this form as *

4. Review your requestI confirm that the information I entered is accurate to the best of my knowledge, that I am the patient or authorized to make this request, and that I would like Apogee to contact me about it. *

This is a request for contact and review. It does not confirm an appointment, establish eligibility, or replace a clinician’s order when one is required.

Your starting point for care.

Your patient self-referral

Save and share your request.