Specialist Referrals Form

Thank you for choosing to refer your patient to Specialists on Rocket Doctor’s platform. Please note that this form will be reviewed by Rocket Doctor support staff, who will allocate it to the requested specialist. We strive to present all external referrals to specialists within a 2-3 day period of time and help specialists on the platform reply to the consultation request within 2-3 weeks. If for extenuating circumstances you have not received a reply within this period of time, please email specialists@rocketdoctor.io to follow-up
Patient Details
Patient Name:*

Patient First NamePatient Last Name
Patient Phone Number*
Please enter a valid phone number.
Patient Email*
example@example.com
Patient Date of Birth:*

MonthDayYear
Date
Patient Health Card Number
Patient Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Specialty requested*
Reason for Referral:
Referring Physician Details
Referring Provider Name:*
Provider Phone Number*
Please enter a valid phone number.
Referring Physician Fax Number:*
Referring Physician Billing Number:*
Type N/A if not applicable
Should be Empty:

Patient Details