To refer a patient for an appointment, please complete the form below and your patient will be contacted for scheduling. Fax referral forms may be sent to 303.270.2162.
You may also contact our Physician Line at 1.800.652.9555, Monday - Friday, 8:00 am to 5:00 pm Mountain Time or firstname.lastname@example.org.
For mycobacterial disease referrals, complete the Mycobacterial Referral/Consult form.
Other resources: Order a test | General Physician Consults |
Name of requesting office or facility
Provider International Address
If yes, please select:
Patient Phone Number
DX and Brief history
(Please include something in addition to the ICD9 code)
Other medical problems
PLEASE NOTE: Our system does not accept attachments. If you attempt to attach a document, the information will not be processed.
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