Outside Referral Forms

Outside Referral Form

This form is required for non-Parkland providers referring patients to a Parkland primary care or specialty clinic.

Please download the form and provide complete information on patient demographics, patient funding source, referring provider information, reason/diagnosis for referral and specify the destination clinic.

Download Outside Referral Form

Outside Referral Form Dividers

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These documentation dividers are for the required information that must accompany the Outside Referral Form.

When submitting required documentation along with the Outside Referral From, place the appropriate divider before each section.

Download Outside Referral Form Dividers

Patient Information Sheet for Interventional Pain Management Clinic

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This form is required, in addition to the Outside Referral Form, when a patient is being referred to the Pain Management Clinic.

Provide patient medication history and substantiate patient’s intent to continue care at Parkland.

Download Patient Information Sheet for Interventional Pain Management Clinic