"Patient Referral Form"

A Patient Referral Form is a written document prepared to arrange a transfer of an individual from one doctor to the other. Whether the patient is seeking a second opinion and you want to collaborate with the other doctor treating the person in question or their diagnosis warrants a more extensive treatment, this statement will help any physician to ask for assistance, share thoughts about the patient's condition or injury, and help the individual heal quicker. Offer your professional opinion about the patient's health condition, mention their medical history, and provide the other doctor with recommendations regarding the treatment and medication the patient should continue taking.

You may download a Patient Referral Form template through the link below. State the date of referral, add the name of the prospective new physician, specify the medical institution where the patient will undergo treatment, indicate the patient's personal information and contact details, list the reasons for the referral - for instance, they require advanced treatment or specific procedures you cannot perform or offer at your facility, and add your personal details, including telephone number and e-mail to let the referral recipient reach out to you for clarifications.


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Patient Referral Form
Referral Date​
_ _________________________
Referral to ____________________________
____________________________
Doctor
Clinic
1. Patient Information.
_______________________________
_______________________________
Patient’s Name
Date of Birth
_______________________________
_______________________________
Patient’s Phone Number
Best Time to Call
_______________________________
_______________________________
Patient’s Email
Patient’s Fax
_____________________________________________________________________
Street Address
City
State
ZIP Code
Reasons for Referral: ___________________________________________________
_____________________________________________________________________
2. Referring Doctor Information.
_______________________________
_______________________________
Referring Doctor’s Name
Referring Doctor’s Clinic
_______________________________
_______________________________
Referring Doctor’s Phone Number
Referring Doctor’s Fax
_______________________________
_______________________________
Provider Number
Referring Doctor’s Email
_____________________________________________________________________
Primary Practice Address
_______________________________
Referring Doctor’s Signature
©​ ​ ​ ​
T EMPLATEROLLER.COM​
Patient Referral Form
Referral Date​
_ _________________________
Referral to ____________________________
____________________________
Doctor
Clinic
1. Patient Information.
_______________________________
_______________________________
Patient’s Name
Date of Birth
_______________________________
_______________________________
Patient’s Phone Number
Best Time to Call
_______________________________
_______________________________
Patient’s Email
Patient’s Fax
_____________________________________________________________________
Street Address
City
State
ZIP Code
Reasons for Referral: ___________________________________________________
_____________________________________________________________________
2. Referring Doctor Information.
_______________________________
_______________________________
Referring Doctor’s Name
Referring Doctor’s Clinic
_______________________________
_______________________________
Referring Doctor’s Phone Number
Referring Doctor’s Fax
_______________________________
_______________________________
Provider Number
Referring Doctor’s Email
_____________________________________________________________________
Primary Practice Address
_______________________________
Referring Doctor’s Signature
©​ ​ ​ ​
T EMPLATEROLLER.COM​