Patient Referral  

Specialty Service Referral Form

Please complete the patient referral form and submit along with any relevant medical records. A member of our team will contact you shortly to facilitate further communication and expedite your patient’s care.

If you need additional assistance, have questions or would like to discuss your patient’s care prior to referral please contact us at 503-656-3999.

For emergencies, you must call for approval from an ER Doctor (503-656-3999, option 1).

Prefer to email or fax in your form?
Please download and email or fax it to us at 503-557-8672

Contact Information

Services Requested

If available,
  • Medical Notes/Records
  • Imaging
  • Lab Work Results
  • Treatments, including last time administered
  • X-Rays
  • Other

Guardian Information

Patient Information


We respect your privacy and will not share your information with other parties. For more information, see the Privacy Policy.