Either fill out the online patient referral form or fax or email in the PDF fax referral form.
Our online form makes it easy to submit patient information and allows us to receive your request as quickly as possible. If you’d prefer to fill out a paper form and fax or email it in, click the ‘Fax Referral Form’ link below, then please fax forms and patient information to (719) 227-0669.
Provide required patient information whether submitting online or via fax/email.
We request the following information to be submitted with all referrals:
Patient Information & Demographics
Referring Physician Information
If you have an emergent referral and would like for your patient to be seen as soon as possible, please call us directly at (719) 473-9595 ext. 0.