Free Blank Medical Referral Letter Template
Blank Medical Referral Letter
[Your Name]
[Title]
[Your Company Name]
[Your Company Address]
[Your Company Number]
[Your Company Email]
[Date]
[Specialist’s Name]
[Specialist’s Title]
[Specialist’s Facility Name]
[Specialist’s Address]
[City, State, ZIP Code]
[Phone Number]
[Email Address]
Subject: Referral for [Patient’s Full Name]
Dear Dr. [Specialist’s Last Name],
I am referring [Patient’s Full Name], a [Patient’s Age] year-old [Patient’s Gender], for your evaluation and management. The patient has been experiencing [brief description of symptoms or reason for referral].
Patient’s Medical History:
-
Current Diagnosis: [Diagnosis]
-
Current Medications: [Medications]
-
Relevant Past Medical History: [History]
-
Recent Diagnostic Results: [Results]
Requested Action:
-
[Specific tests, evaluations, or treatments requested]
Please find attached [any relevant documents or test results]. I would appreciate it if you could evaluate the patient and provide your recommendations.
Thank you for your attention to this matter.
Sincerely,
[Your Name]
