2800 Freeway Blvd, Suite 204, Brooklyn Center, MN 55430

Make a referral

"*" indicates required fields

Contact Information

Referent Name*
Referent Address*

Patient Information:

Patient Name*
MM slash DD slash YYYY
Patient Address*

Patient Health Insurance Information:

Upload Documents

If you would like to upload a document as part of your referral (such as discharge paperwork, medical records, or release forms), please use the button below to select files to upload.
Drop files here or
Max. file size: 20 MB.
    How did you hear about us?

    Thank you for referring a client to Kisma Flame Lily LLC. By clicking "Submit," you confirm that the information provided is accurate and you have obtained consent from the referred individual. Our team will review the referral and reach out as needed.

    Scroll to Top