Referral Request Form

Asks about policy number, referring provider name, and referred to (Specialist/Provider). Built for primary care referrals to specialists.

Questions: 17
Page: 1
Time: about 4 min

File upload

Your practice

Patient Name

Date of Birth

Phone Number

Insurance Provider

Policy Number

Referring Provider Name

Referred To (Specialist/Provider)

Specialty

Urgency

RoutineUrgent (within 1 week)Emergent (within 24-48 hours)

Reason for Referral

Relevant Diagnosis / ICD Code

Relevant Medical History

Current Medications

Attach Supporting Documents (lab results, imaging, etc.)

Choose a file or take a photoUp to 10 MB

Special Instructions or Notes

Live preview. Tap through it like a patient.

Who it is for

Primary care referrals to specialists
Inter-departmental referrals within health systems
Diagnostic imaging and lab referral coordination
Care coordination for multi-specialty patient management

What's inside

Patient NameText · Required
Date of BirthDate · Required
Phone NumberPhone · Required
EmailEmail
Insurance ProviderText
Policy NumberText
Referring Provider NameText · Required
Referred To (Specialist/Provider)Text · Required
SpecialtyDropdown · 15 choices · Required
UrgencyMultiple Choice · 3 choices · Required
Reason for ReferralLong Text · Required
Relevant Diagnosis / ICD CodeText
Relevant Medical HistoryLong Text
Current MedicationsLong Text
Attach Supporting Documents (lab results, imaging, etc.)File Upload
Special Instructions or NotesLong Text
DateDate · Required

From form to a ready patient

01
Make it yours
Reword, reorder, or add to the Referral Request Form, and add your logo.
02
Patients finish it at home
A secure link by text or email, filled out on their phone before the visit. No app.
03
Your team sees who is ready
Each visit shows as ready once its forms are in. Answers land on the patient record.

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Questions

Responses are encrypted, only your team can see them, and a BAA is included.

Yes. You can add, remove, reorder, or reword any of the 17 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Yes. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Send it before the visit, so patients arrive ready.

Book a short call and we will set up the Referral Request Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

Use this template