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.

This template includes Person fields and Lookup fields that pull in data from the Healthcare Employee Lookup form, making it easier for both your clients and internal team to complete this form.

Connected Forms:

This template includes one connected form to help you manage your data more efficiently:

• Healthcare Employee Lookup: The form is the source of your healthcare practice’s employee information, housing data on the physicians, nurses, admin staff, and any other employee roles you have. This form is connected to a Person field in the doctor referral form that lets you select a physician from the list of employees added to this form. We also have a lookup field tied to this form that automatically pulls in a physician’s practice area after they are selected from the list of employees in the Person field. A Person field is also used in the Internal Section to automatically pull in the name of the internal staff member who logged in when making updates, saving you time and further automating your processes.

You can easily customize this template for your practice by adding, removing, and editing fields to fit your needs. Quickly brand it with your logo and style using our Themes feature.