Use our free physician referral form template to refer your patients to specialists when necessary.

The template includes sections to collect the receiving doctor’s information, the referring physician’s information, as well as detailed information about the patient – so the doctor receiving the referral has all the necessary information to provide the best care possible!

All data collected can be made HIPAA compliant on our Enterprise plans after signing our Business Associates Agreement (BAA). Additionally, our data encryption capabilities can help ensure your data is secure at rest and in transit.

An internal section is included for your referral coordinator to log updates as they are made – like whether or not the referral has been sent to the specialist or if a copy of the completed referral has been uploaded to the patient’s file. Using our Entries page and workflow statuses, your referral coordinator can easily keep track of the status of each referral throughout the process.

Easily customize the template for your practice by adding, removing, and editing fields to fit your needs. Quickly brand it with your logo and style using our Default Themes feature.