Patient Referral Form | UT Physicians

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.

Name*

First Last

Patient Date of Birth*

Reason For Referral

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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