Refer a Patient

Please include:

• Reason for referral: what is the clinical question for the specialist?
• If the referral is urgent (see within 4 weeks) or routine (next available)
• ICD-10 Diagnosis – required
• Visit type:
  • New patient consult, transfer of care, second opinion, or return visit/ongoing care
• ALL relevant clinical documents
  • Clinic notes
  • Medication history
  • Growth charts/curves 
  • Lab reports
  • Imaging and diagnostic reports
  • Previous specialty evaluations
• Patient’s full name (legal name and chosen name, if different), DOB, sex, address, guardian contact information and insurance
• Referring provider’s name, phone, fax and the referral coordinator’s email address so that we may contact you if additional information is needed
• Preferred clinic location, if applicable
• If an interpreter is needed
• Any known barriers to performing a successful telehealth (video) visit with the family

Referral requirements

Please submit a referral that is complete. This helps us schedule your patient’s appointment in a timely manner and ensure their first visit is smooth and productive.    

We may not schedule patients until a complete referral is received.