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Centered referral form on cream background with floral frame, white card, two labeled sections, and full-width submit button.
Summary
A Make a Referral page with HIPAA note, patient and provider field groups, and terms checkbox on a warm illustrated backdrop.
Visual description
Warm cream background with soft horizontal gradient and illustrated pink-blossom trees framing left and right edges. Centered navy serif Make a Referral title, gray sans intro about HIPAA compliance and required asterisk fields. Large white rounded card with shadow containing Patient Information section with two-column name, phone, email, insurance, state dropdown, and full-width Conditions and Patient Notes textareas; Referring Provider section with parallel fields plus Organization, Title/Specialty, NPI, and Other Provider Information. Bottom checkbox for Terms and Conditions and full-width blue-gray Submit Form button.
Key takeaway
Splitting patient and provider data into labeled sections reduces cognitive load on long medical forms. Floral frame softens compliance-heavy content. Full-width submit on white card signals one decisive action.
Reuse notes
B2B healthcare referral or intake flows. Long forms need progressive disclosure on mobile. HIPAA copy must be legally reviewed, not decorative.
