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 ClearCaptions, LLC and its agents to contact you using an automatic telephone dialing system (ATDS) or artificial/prerecorded voice at the phone number provided, including via SMS/MMS messages, for marketing, promotional, advertising, offers, surveys, account updates, transactional, and informational purposes, potentially exceeding three calls within a 30-day period; you expressly consent to receiving such messages at any time, including before 8:00 a.m. or after 9:00 p.m. local time, on weekdays, weekends, and holidays; consent is not required to purchase goods or services; message and data rates may apply; and you may revoke consent at any time by texting STOP or contacting 866-992-2192. ClearCaptions' Privacy Policy and Terms of Use apply.
This field is for validation purposes and should be left unchanged.

If you would prefer to mail a form please click here