Referring Physicians

refer New Patients Here

Thank you for referring your patient to our practice. You may either submit the form on this page or fax a referral to our office at 405-942-6448.

Please include with your referral any pertinent medical records including clinic notes, lab results and recent ultrasounds.

We will initiate contact with your office and referred patient following a review of records by our physician. If we cannot schedule your patient, we will notify you. If you have any questions, please call our office at 405-942-5442

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Today's Date*

Briefly describe the reason for the referral*

Okay to schedule with 1st available physician?*

Yes

If not, which physician is preferred?*

Patient Name*

First Middle Last

Gender*

Male

Female

Date Of Birth*

Patient Address*

Street Address Apt, Unit # City State ZIP Code

Social Security Number (last 4 Digits)*

Patient contact numbers for scheduling

Primary Phone*

Secondary Phone

All insurance information must be provided and authorization obtained prior to scheduling

Primary Insurance*

ID Number*

Group Number*

Secondary Insurance

ID Number

Group Number

Referring Provider Name*

Referring Provider Email*

Enter Email Confirm Email

Referring Provider Address*

Street Address City State ZIP Code

Referring Provider Phone*

Referring Provider Fax*

Attach Medical Records Here (Optional)

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.

Thank you for your referral!

We look forward to providing your patients with quality, compassionate medical care. If you have any questions, please feel free to call us at (405) 942-5442

Our Services

Our practice is focused on continually seeking improved methods and the newest technologies to effectively diagnose and treat patients with kidney disease.