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Once you have filled out the form, click on SUBMIT to send your request. Fields marked with and asterisk (*) are required.

Physician Referral Form
Information about the Referring Physician:
Physican Name *
Hospital/Clinic Name *
City/Municipality *
State/Province *
Country
Office Phone *
Office Fax *
Information about the Patient
Patient's Name *
Gender *	Male Female
Date of Birth (MM/DD/YYYY)
Street Address
City
State
Zip
Phone (day)
Phone (evening)
Fax Number
E-mail
Diagnosis Information
Is this patient currently under treatment? *	Yes No (If no, please continue to next section)
Current Treatment Clinic
Current Treatment Method	Select Treatment Method Not Currently Under Treatment Chemotherapy Hormone Therapy Radiation Therapy Surgery Other (Combinational) None
Specify if Other
Diagnosis Date (MMDDYYYY)
Diagnosis Method	Select Diagnosis Method Biopsy Lab Work CT Scan MRI Ultrasound X-Ray Cytology Other (Combinational)
Specify if Other
Referral Information
Are you referring to a specific physician?	Yes No
Physician Name
Our Referral Specialists will call your office to discuss this referral further and to obtain additional information if needed. If convenient, please indicate the contact person who can best assist with this referral.
Contact First Name
Contact Last Name
Contact Title
Contact Phone Number (area code first)
You may be contacted to review insurance coverage and obtain additional information. Medical and financial eligibility need to be established prior to confirming an appointment. If you would like to leave a further message, type it here.
Message for Referring Staff
Duke Health System respects your confidentiality. Information you provide will only be used in the confines of the Health System for the explicit purpose of providing the best quality health care for your patients.

* Required