Medical Referral Form

A medical referral form is a template consists of medical form in which it is aimed to process a patient from one doctor to another or from one hospital to another. The medical referral form itself refers to the process of referring or directing a patient for a medical reason to another physician that is considered to be more appropriate in encountering his medical case. It is hoped to make the patient have proper treatments.

There are some steps that can be followed to make a template of medical referral form.

  1. Knowing the need of referring a patient to another doctor or hospital. It is important to make everyone understands that the patient might require some advance treatment and the doctor should be treating his patient according to his capability.
  2. Addressing the doctor’s name with a proper credential.
  3. Making sure that the patient knows that he should be redirected to another doctor and he will probably take an advance steps.
  4. Verifying the information of the patient including his address, email, phone number, and so on.
  5. Providing information that is only required for assessment inquiry for the ‘new’ doctor.
  6. Writing the ‘new’ doctor or referring doctor’s personal information such as: email, phone number, fax number, and address.
  7. Making it simple and short yet understandable
  8. Copying the file for the patient, the ‘previous’ doctor, and the ‘new’ doctor.
  9. Sending the medical referral form to the ‘new’ doctor

The basic medical referral letter template provides these components:

  • Date

The date when the referral form is made should be provided. It is usually written in the top of the letter.

  • A patient information

It should provide the information of the patient such as the full name, phone number, address with the details, and date of birth.

  • Symptoms

The symptoms that the patient encounter is also important to be provided in the referral form. It helps to diagnose the disease and to let the referring doctor know as well.

  • Results

The result after performing medical assessment, for example, requires to be written in this section to assess the diseases.

  • Treatment given

If the previous doctor had given any treatments to the patient then it is necessary to be reported. It also aims to let the referring doctor know what have been down by the previous doctor.

  • Probable diagnose

It shows the most possible disease of the patient after doing medical examination and giving treatments.

  • Allergies

If the patient has allergies, it is required to write them down here.

  • Family diseases

It helps the doctor to diagnose the patient’s diseases.

  • Reasons for referral

It is important to provide the reasons why the patient should be referred



A medical referral form should provide clear information about the patient who requires the referral and the referring doctor who the patient will be taken care of. It is also important to provide the reasons of referral why the patient needs to get another doctor whether it is for taking some advance treatments or for referring to a proper doctor that the patient might have taken a ‘wrong’ specialist for his case.