Thank you for trusting us with the care of your clients and patients. Our referral relationships are extremely important to us and we want to support your hospital teams as efficiently as possible. Please find the dedicated resources below to assist in your referrals and transfers to our facility. Various referral forms are available, which may be downloaded and completed in advance of sending your client and patient. If preferred, below is a fillable referral form that can be submitted online. 

Referral Forms:

Specialty Patient Referral Form
Diagnostic Imaging Referral Form 
Critical Care Transfer Form

Sending Records:

Prior to the patient’s visit with us, please send all pertinent medical records, lab work, and imaging.

Surgery, Radiology, & Emergency Departments: 
E: [email protected]
P: 310.473.5906 / 310.473.1561
F: 310.479.8976

Cardiology Department:
E: [email protected]
P: 310.473.5906 Option 2
F: 310.479.8976

Internal Medicine Department: 
E: [email protected]
P: 310.473.5906 Option 3
F: 310.479.8976

Oncology Department: 
E: [email protected] 
P: 310.473.5906 Option 4
F: 310.479.8778

Appointments:

  • Specialty Departments are available by appointment only. Please contact the desired department for more details.
  • Emergency Department is available 24-7 for urgent situations- no appointment required. 

  • Need Help?

    For questions about our referral process or to request ASEC materials, please contact:

    Lindsey Olmos – Relationship & Marketing Manager
    E: [email protected]
    P: 310.473.5906 ext. 235 

    Please contact departments directly for any scheduling questions.

    For Your Clients:


    Downloadable ASEC Brochure
    Navigating Your ASEC Visit

    Referral Form

    All fields are required unless otherwise stated

    Some information is missing. Please see below for details.

    (optional)
    (optional)
    Services Requested
    (optional)
    (optional)
    (optional)
    (optional)
    If available, please send the following with your client; patient information to include:
    • Medical Notes/Records
    • Imaging
    • Lab Work Results
    • Treatments, including last time administered
    • X-Rays
    • Other
    Guardian Details
    (optional)
    (optional)
    (optional)
    Patient Details
    Sex
    Tentative Diagnosis/Chief Complaint
    History/Physical Findings (optional)
    Treatment (including medications and dosages) (optional)
    Special Requests/Comments (optional)
    We respect your privacy and will not share your information with other parties. For more information, see the Privacy Policy.

    Some information was missing. Please see above for details.

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