Make a Referral

Image Here — UT Southwestern Patient Referral Program

UT Southwestern: Your Partners in Patient Care

UT Southwestern offers care in more than 80 specialties and subspecialties, ranging from Allergy and Immunology to Vascular Surgery – and just about everything in between.

Our specialists will provide your patient with a multidisciplinary team approach to their care, drawing on the deep well of medical expertise and research available at our academic medical center.

Providers who want to make a referral should complete the form below.

All fields required unless indicated.

PATIENT INFO

Patient Name* Patient Phone* Patient Date of Birth* Gender*

Diagnosis* Reason for Referral*

Preferred Appointment Type*

Preferred UT Southwestern Provider* Insurance Provider (Optional)
If not listed, your insurance provider is not currently accepted.

REFERRING PROVIDER INFO

Referring Provider First Name* Referring Provider Last Name* Referring Provider Phone* Referring Provider Zip Code*

Make a Referral

UT Southwestern: Your Partners in Patient Care

Providers who want to make a referral should complete the form below.

PATIENT INFO

REFERRING PROVIDER INFO

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