{"id":11418,"date":"2026-01-06T21:19:41","date_gmt":"2026-01-06T21:19:41","guid":{"rendered":"https:\/\/amcenetstg.wpengine.com\/?page_id=11418"},"modified":"2026-03-25T12:10:54","modified_gmt":"2026-03-25T12:10:54","slug":"refer-a-patient","status":"publish","type":"page","link":"https:\/\/www.amce.net\/fr\/refer-a-patient\/","title":{"rendered":"Refer A Patient"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"11418\" class=\"elementor elementor-11418\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\">\n\t\t\t\t        <section class=\"elementor-section elementor-top-section elementor-element elementor-element-63b60ca elementor-section-boxed elementor-section-height-default elementor-section-height-default pxl-row-scroll-none pxl-zoom-point-false pxl-section-overflow-visible pxl-section-fix-none pxl-bg-color-none pxl-section-overlay-none exad-glass-effect-no exad-sticky-section-no\" data-id=\"63b60ca\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\n                \n                <div class=\"elementor-container elementor-column-gap-default\">\n                <div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-ec175ca pxl-column-none pxl-column-overflow-hidden-no exad-glass-effect-no exad-sticky-section-no\" data-id=\"ec175ca\" data-element_type=\"column\" data-e-type=\"column\">\r\n        <div class=\"elementor-widget-wrap elementor-element-populated\">\r\n                     \r\n        \t\t<div class=\"elementor-element elementor-element-9e808f8 exad-sticky-section-no exad-glass-effect-no elementor-widget elementor-widget-pxl_contact_form\" data-id=\"9e808f8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"pxl_contact_form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t    <div class=\"pxl-contact-form pxl-contact-form1 btn-w-auto\" data-wow-delay=\"ms\">\r\n        \n<div class=\"wpcf7 no-js\" id=\"wpcf7-f11476-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"11476\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/fr\/wp-json\/wp\/v2\/pages\/11418#wpcf7-f11476-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\" data-trp-original-action=\"\/fr\/wp-json\/wp\/v2\/pages\/11418#wpcf7-f11476-o1\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"11476\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f11476-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<div class=\"uacf7-form-11476\"><div class=\"amce-referral\">\n  <h2>Refer a Patient<\/h2>\n\n  <!-- 1) Referring Clinician Information -->\n  <h3>Referring Clinician Information<\/h3>\n\n  <label>Referring Physician Name*<br\/>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_physician\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"e.g., Dr. Aisha Umar\" value=\"\" type=\"text\" name=\"ref_physician\" \/><\/span>\n  <\/label>\n\n  <label>Hospital \/ Clinic Name<br\/>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_facility\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"e.g., AMCE Abuja\" value=\"\" type=\"text\" name=\"ref_facility\" \/><\/span>\n  <\/label>\n\n  <div class=\"grid-2\">\n    <label>Email Address*<br\/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"name@hospital.org\" value=\"\" type=\"email\" name=\"ref_email\" \/><\/span>\n    <\/label>\n    <label>Phone Number*<br\/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"+234 801 234 5678\" value=\"\" type=\"tel\" name=\"ref_phone\" \/><\/span>\n    <\/label>\n  <\/div>\n\n  <label>Reason for Referral (Short Summary)*<br\/>\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"ref_reason\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Brief summary of case and referral objective\" name=\"ref_reason\"><\/textarea><\/span>\n  <\/label>\n\n  <div class=\"grid-2\">\n    <label>Additional Notes (Optional)<br\/>\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"notes\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Any additional details for the AMCE intake team\" name=\"notes\"><\/textarea><\/span>\n    <\/label>\n  <\/div>\n\n  <!-- Hidden fields for analytics\/CRM mapping (optional) -->\n  <input class=\"wpcf7-form-control wpcf7-hidden\" value=\"\" type=\"hidden\" name=\"utm_source\" \/>\n  <input class=\"wpcf7-form-control wpcf7-hidden\" value=\"\" type=\"hidden\" name=\"utm_medium\" \/>\n  <input class=\"wpcf7-form-control wpcf7-hidden\" value=\"\" type=\"hidden\" name=\"utm_campaign\" \/>\n  <input class=\"wpcf7-form-control wpcf7-hidden\" value=\"\" type=\"hidden\" name=\"referrer_url\" \/>\n\n<span class=\"wpcf7-form-control-wrap\" data-name=\"acceptance-212\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"acceptance-212\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">I agree to AMCE\u2019s Privacy Policy.<\/span><\/label><\/span><\/span><\/span>\n\n  <div class=\"submit-wrap\">\n    <input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit Referral\" \/>\n  <\/div>\n<\/div><\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<input type=\"hidden\" name=\"trp-form-language\" value=\"fr\"\/><\/form>\n<\/div>\n        <div id=\"qrcode\" class=\"hide-qr\"><\/div>\r\n    <\/div>\r\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t            <\/div>\r\n        <\/div>\r\n        \t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"<p>Refer a Patient Referring Clinician Information Referring Physician Name* Hospital \/ Clinic Name Email Address* Phone Number* Reason for Referral (Short Summary)* Additional Notes (Optional) I agree to AMCE\u2019s Privacy Policy.<\/p>","protected":false},"author":5,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-11418","page","type-page","status-publish","hentry"],"featured_image_src":null,"featured_image_src_square":null,"_links":{"self":[{"href":"https:\/\/www.amce.net\/fr\/wp-json\/wp\/v2\/pages\/11418","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.amce.net\/fr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.amce.net\/fr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.amce.net\/fr\/wp-json\/wp\/v2\/users\/5"}],"replies":[{"embeddable":true,"href":"https:\/\/www.amce.net\/fr\/wp-json\/wp\/v2\/comments?post=11418"}],"version-history":[{"count":0,"href":"https:\/\/www.amce.net\/fr\/wp-json\/wp\/v2\/pages\/11418\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.amce.net\/fr\/wp-json\/wp\/v2\/media?parent=11418"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}