Physician Referral Form Template

Home / ... / Physician Referral Form Template

Available on a Paid Plan

This physician referral form template enables physicians to give and accept referrals or consultation requests online. Help patients get the assistance they need from the right professional with this easy to create and customize template from 123FormBuilder. Don’t get lost in tons of paperwork and lose track of your patient’s medical assistance. Share the online physician referral form template with our colleagues. They can quickly describe the patient’s medical history, recommendations, and other contact details. Create your form right away; no coding needed, just an account on our form builder.

Use Template

Show more templates

Frequently Asked Questions

How do I create a referral form?

To help you speed up this part of the process, use the physician referral form template from 123FormBuilder and customize it. Don’t worry; you don’t need any technical skills. Use our drag and drop tool to add or remove fields and include your practice’s branding elements. Connect it to your favorite apps and tools and have your patient’s data safely stored in your system.

What should a referral form contain?

It’s up to you what you include in the referral form, but here are our recommendations for what to cover.
– The patient’s contact and personal details
– The physician’s name and contact information
– The diagnosis and the patient’s clinical information
– Reason for referral
– Patient’s medical history, including medications, restrictions, allergies, etc.
– Insurance information (if applicable)
– Time and date of referral and a signature

Start with this template