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Patient Referral Form Template

Simplify the Patient Referral Process with Ease

Struggling to streamline patient referrals in your practice? This patient referral form template helps healthcare professionals quickly and effectively refer patients to specialists, ensuring timely and coordinated care. Save time, minimize errors, and enhance patient satisfaction while remaining compliant with medical standards and regulations. Whether you're managing a busy clinic or working in a specialized setting, this form is designed to meet your needs and improve communication among providers. Try out the live template to see how it works for you.

Use this Template (FREE) Live Preview
Type of service requested
Reason for referral
Urgency
Routine (4-6 weeks)
Soon (2-3 weeks)
Urgent (within 72 hours)
Patient full name
Date of birth
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Patient phone number
Patient email address
Preferred contact method
Phone
Email
Text message
No preference
Primary diagnosis or concern
Brief clinical summary
Current medications
Allergy details
Allergies
No known allergies
Yes - specify below
Unknown
Insurance provider
Member ID or policy number
Insurance coverage type
Private insurance
Medicare
Medicaid
Self-pay
Workers' compensation
Unknown
Other
Please Specify:
Referring provider name
Practice or organization
Provider phone
Provider email
Has the patient consented to share medical information for this referral?
Yes
No
Not applicable
Referring provider typed signature (full name)
Date signed by provider
I certify that the information provided is accurate to the best of my knowledge.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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Paper art illustration featuring a patient referral form design for FormCreatorAI article

When to use this form

When you need to transfer care or request a consult, this form standardizes the handoff. Use it in primary care, specialty clinics, hospitals, dental practices, and home health agencies. For example, a family doctor can send history and reason for consult to a cardiologist; a dentist can route a patient to an oral surgeon; or a discharge planner can coordinate skilled nursing. It speeds triage, captures clinical context, and sets next steps without phone tag. If you need a specialty-specific option, try our Physician referral form or Dental referral form. For post-acute transitions, pair it with the Home care referral form to share contact details, coverage, and visit orders.

Must Ask Patient Referral Questions

  1. What is the patient's full name, date of birth, and best contact information?

    Accurate identifiers prevent mix-ups and help the receiving office locate the right chart. Including phone and email enables quick scheduling and clarifications.

  2. What is the reason for referral, working diagnosis, and level of urgency?

    This gives the specialist clear context and helps prioritize the appointment. Naming urgency (routine, soon, urgent) guides triage and waitlist management.

  3. Which pertinent history, medications, allergies, and recent results should be reviewed?

    A brief clinical snapshot avoids duplicate testing and risks like drug interactions. Attach or summarize key labs, imaging, and notes from the last 6 to 12 months.

  4. What insurance plan, member ID, and authorization or referral number apply?

    Coverage details reduce denials and surprise bills for your patient. If pre-approval is pending, note the status and who to contact.

  5. Who is the referring provider, and how should the receiving office follow up?

    Listing your name, role, NPI, and preferred contact streamlines coordination and report-back. If your clinic accepts self-initiated requests, reference the Self referral form to guide patients.

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