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Patient Referral Form
At UT Physicians, we understand that when you refer your patient, you expect them to be treated with exceptional care. As specialists, our standard is to always keep the referring physician informed of a patient’s status and treatment plan. We are in constant communication with our referring physicians, working together in the best interest of the patient. To refer your patient, please complete this form or call 888-4UT-DOCS.
Patient's Name
*
First
Last
Patient Date of Birth
*
Date Format: MM slash DD slash YYYY
Reason For Referral
Urgent
Routine
Other
Please add other reason for referral
Please specify specialty:
*
Parent / Guardian Name
First
Last
Patient Phone
*
If patient is aged 17 or under, please provide parent / legal guardian phone number.
Patient Email
*
If patient is aged 17 or under, please provide parent / legal guardian email address.
Referring Physician Name
*
First
Last
Referring Physician Phone
*
Referring Physician Email
*
Any additional information we need to know?
UT Physicians uses Transport Layer Security (TLS) encryption (also known as HTTPS) for all transmitted data. We also protect all individual internal form data with passwords. Our data is hosted by data centers that are SSAE-16 SOC II certified. To request a free copy of our latest UT Physicians Resource Guide for Referring Physicians, please
contact us
.
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