healthcare

Patient Referral

Referral letters from primary care to specialists contain critical clinical context that often gets lost in fax-and-phone workflows. This template captures the referring provider, patient demographics, clinical indication, relevant test results, urgency level, and any specific specialist or facility requested.

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What users type

Dr. Sarah Lehman at Pine Valley Family Medicine is referring patient Margaret Cho (DOB 11/28/1971) to a gastroenterologist. Mrs. Cho has had unexplained weight loss of 15 lbs over 4 months with intermittent abdominal pain and a family history of colon cancer. Recent CBC was normal but FOB was positive. We'd like her seen within two weeks if possible.

What you get

Patient Name

Margaret Cho

99%

Date of Birth

1971-11-28

98%

Referring Provider

Dr. Sarah Lehman

99%

Referring Facility

Pine Valley Family Medicine

98%

Specialist Type

Gastroenterologist

99%

Clinical Reason

Unexplained 15lb weight loss over 4 months, intermittent abdominal pain, positive FOB, family history of colon cancer

97%

Urgency

Urgent

94%

Extracted fields

Field	Type	Required
Patient Name	text	Required
Date of Birth	date	Required
Referring Provider	text	Required
Referring Facility	text	Optional
Specialist Type	text	Required
Clinical Reason	text	Required
Urgency	select	Required

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Patient Referral

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Extracted fields

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