Patient Referral Form Template

A referring provider can send a patient's contact details, referral reason, urgency, relevant history, and records to a receiving clinic.

Use this template free

When to use it

• A primary care clinic is referring a patient to a specialist.
• A provider needs to share relevant history and test results with another clinic.
• A receiving clinic needs to know how urgently to schedule a patient.
• A clinic wants a consistent way to collect referral details.

What it asks

1. Your name
2. Your email
3. Your phone number
4. Referring clinic
5. Patient's full name
6. Patient's date of birth
7. Patient's phone number
8. Reason for referral
9. How urgent is this referral?
10. Relevant history
11. Attach relevant records or test results

Why it should be encrypted

Patient identifiers, health history, and attached records are sensitive. Only the authorized referring and receiving care teams should be able to read them.

Tips

• Tell referring providers which receiving clinic or department should get the referral.
• Explain which records or test results to attach and what file types you accept.
• Clarify how to handle urgent referrals that need attention sooner than a form response.

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