Patient Referrals

This web page is meant for patient referrals from medical and legal professionals.  If you are a patient, please use our Contact Us page to send us a message.

Thank you for considering a referral to our practice.  We take the trust our partners place in us seriously.  Collaborative care leads to the better outcomes for patients.  We will work with you to ensure continuity of care and collective results.

We will respond to every referral sent within 1 business day and contact the patient for appointment scheduling.  Once your patient is scheduled we will notify you.  If there is any issue with scheduling the patient we will also notify you.  Once the patient is seen we will provide you with feedback, as appropriate.

We provide multiple options for you to send us a referral:

  • Fax / Email:  Download and complete our referral form and securely email it to [email protected] or fax it to (832) 532-4417.  If your office has its own form used for referrals, you can send us that instead.
  • Phone:  Call us at 713-722-1700 and choose the option for new patients.
  • Online Form:  Complete the online form below, it will be securely delivered to our new patient coordinator.  We will call to verify and confirm all online referral form submissions using the phone number provided.

Please ensure you have appropriate consent for any protected health information you send to us.  If in doubt, please omit this and we will coordinate appropriate authorization and release for medical records, as needed.  You can use our standard medical records release form if needed.  If you have any questions please email us at [email protected] or call us at 713-622-1700 and select the New Patient option.

 

Online Referral Form

You can submit referrals online to us using our secure online form.  Please ensure you have appropriate consent before submitting any protected health information.

You can use our standard medical records release form and attach it to the referral if you don't have another appropriate form of medical records release.  Alternatively, just complete the basic required information for the referral and we will coordinate any future and appropriate medical records release authorization and retrieval with your office.

PATIENT INFORMATION

Patient Name(Required)
Enter phone number where we can reach the patient
Enter the e-mail address for the patient
Select the clinic location preferred by patient.

REFERRING PROVIDER INFORMATION

Your Name(Required)
Enter a phone number where we can reach you if we have questions about this referral.
Enter a secure e-mail address where we can communicate with you regarding this referral.
Describe the reason for the referral
Attach any relevant files related to your referral request. Do not send any files with protected health information unless you have appropriate consent from the patient.
Drop files here or
Max. file size: 100 MB.
    Consent(Required)
    This form is meant for humans, please confirm...