Refer a patient

Use this form to refer a patient to ClearCaptions. If you’d prefer to download a form to mail, scroll to the bottom of the page for a link to download the form.

As a health provider, you are recommending your patient for ClearCaptions’ IP CTS service, based on their hearing loss and need for captions to use the phone.

Referral form

"*" indicates required fields

Area Code first. Do not add a 1.
Area Code first. Do not add a 1.
By entering your phone number and clicking "Submit", you consent to receive phone calls and/or SMS messages from ClearCaptions LLC and its affiliates via automated technology, including autodialed calls, automated texts, and pre-recorded or artificial voice messages, for marketing, advertising, and transactional purposes. You agree that we may contact you at the telephone number(s) you provide, even if your telephone number is on a national or state Do Not Call list. Your consent is not required as a condition of purchase. You also agree to ClearCaptions' Privacy Policy and Terms of Use. Message frequency varies. Message and data rates may apply. See our Privacy Policy.
This field is for validation purposes and should be left unchanged.

If you would prefer to mail a form please click here