Patient Referral Form

This referral form is intended for use by licensed healthcare providers who wish to refer a patient to Iatria General Medicine for ongoing care, consultation, or evaluation. Please complete the fields below with accurate and up-to-date information to ensure a smooth transition of care. All information submitted will be handled securely and in accordance with HIPAA privacy regulations. If you have any questions or need assistance with the referral process, please contact our office directly.

Referring Provider Information

Provider Name *

Provider Email *

Practice Name

Practice Address

Practice Phone *

Patient Information

Full Name *

Date of Birth *

Phone Number

Email Address

Address

Preferred Timeframe for Appointment

Already Scheduled

As soon as possible

Within 2 weeks

Routine (next available)

Other (explain in notes)

Special Instructions / Notes

Clinical Reason for Referral

Primary Reason for Referral *

Brief Clinical Summary *

Upload Any Attachments

Drag and drop files here or Browse Max file size: 256MB

Consent Confirmation *

I confirm that the patient is aware of and has consented to this referral to Iatria General Medicine.

First Name