Physician Resources

Make a Referral

Patients who want to request an appointment can complete the form below, and we’ll contact them within 72 hours. Or, to make an initial appointment by phone, call 214-645-8300. Don’t use this form for urgent medical matters.

For medical emergencies, please call 911 or go to the local emergency room immediately.

All fields required unless indicated.

PATIENT INFO

Patient Name* Patient Phone* Patient Date of Birth* Gender*

Diagnosis* Reason for Referral*

Preferred UT Southwestern Provider* Insurance Provider (Optional)
If not listed, your insurance provider is not currently accepted.

REFERRING PROVIDER INFO

Referring Provider First Name* Referring Provider Last Name* Referring Provider Phone* Referring Provider Zip Code*

WANT TO HEAR FROM US?

Yes! Please sign me up for updates about events, opportunities, and other info.