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* Diagnosis* Reason for Referral*

Preferred UT Southwestern Provider*

REFERRING PROVIDER INFO

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

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