To submit this referral form, first fill out all the required fields using PrintFriendly's PDF editor. Save and download the completed form. Submit the form through one of the following methods: email it to the receiving specialist using the provided email address, fax it to the specialist's office, use an online submission form if available, or mail the physical form to the specialist's office address. Make sure to keep a copy of the submitted form for your records. Our advice is to always confirm the receipt of the form with the specialist to ensure that the referral process is completed smoothly.

There are no specific important dates for this referral form in 2024 and 2025.

The purpose of this form is to facilitate the referral process between primary care physicians and specialists. By providing detailed patient information, major complaints, diagnosis, and any special instructions, this form ensures clear communication and proper coordination of patient care. It helps streamline the referral process and ensures that the receiving specialist has all the necessary information to provide the best possible care. Additionally, the form includes sections for visit details and additional comments, allowing referring doctors to provide comprehensive information. This helps in maintaining accurate medical records and ensuring continuity of care for the patient.

• 1. Referral: Indicates the purpose and reason for the referral.
• 2. Doctor's name & Address: Contains the name and address of the referring doctor.
• 3. Patient: Includes sections for the patient's name, age, sex, DOB, work phone, and other phone.
• 4. Name: The name of the patient.
• 5. Age: The age of the patient.
• 6. Referral for: Specifies the reason and purpose of the referral.
• 7. Major complaint: Describes the patient's primary complaint or issue.
• 8. Diagnosis: Provides the diagnosis made by the referring doctor.
• 9. Special Instructions: Includes any special instructions or guidelines from the referring doctor.
• 10. Referring Doctor's Comments: Contains any additional comments or observations from the referring doctor.
• 11. First visit on: Indicates the date of the patient's first visit.
• 12. Date: The date the form is filled out.
• 13. Sex: The sex of the patient.
• 14. Work Phone: The patient's work phone number.
• 15. Other Phone: An alternative contact number for the patient.
• 16. Reference #: A reference number for the referral.
• 17. DOB: The patient's date of birth.

Failing to submit this referral form can lead to delayed treatment and miscommunication between healthcare providers.

• Delayed Treatment: The patient may experience delays in receiving appropriate care from specialists.
• Miscommunication: Lack of proper referral documentation can result in miscommunication between healthcare providers, impacting patient care.
• Incomplete Records: Failure to submit the form can lead to incomplete medical records, affecting continuity of care.

• 1. Specialist Referral: Use this form to refer a patient to a specialist for further evaluation and treatment.
• 2. Patient Hand-Off: To ensure seamless patient hand-off between healthcare providers.
• 3. Follow-Up Care: To provide specialists with comprehensive patient information for follow-up care.