Please use one form per patient. If the patient needs to be seen within the next week, call 404-785-DOCS(3627) and do not fill out this form.
Date
*
-
Month
-
Day
Year
Date
Referral form completed by
*
First Name
Last Name
Direct contact phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Referring office preferred method of communication
*
Phone
Email
Patient's name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Parent/Guardian
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate number
Please enter a valid phone number.
Format: (000) 000-0000.
Interpreter required?
*
Yes
No
If yes, what language?
Referring provider's name
*
First Name
Last Name
Office phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Office fax
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referring provider status with patient
*
Referring provider is patient’s primary care physician
Referring provider is NOT patient’s primary care physician
PCP name
PCP phone
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for referral
Specialty needed
*
Please Select
Dental/Orthodontics
Pulmonology
Sleep
Specialty Clinic: Brachial Plexus
Synagis
Preferred provider and reason for preference, if applicable:
Have you sent all relevant clinic notes, patient demographics and relevant imaging/diagnostic tests?
*
Yes, I will upload and submit electronically along with this form (use File Upload below)
Yes, faxed previously
No, I will send as soon as possible (Fax: 404-785-9111)
Please indicate if the patient’s diagnostic testing related to this referral was performed at Children’s. If so, please do not fax these records:
*
Yes
No
File Upload
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