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Customizable Medical Referral Form Template

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Try this WPForms&#039; Medical Referral Form Template!" /> <meta name="twitter:creator" content="@easywpforms" /> <meta name="twitter:image" content="https://wpforms.com/templates/wp-content/uploads/2021/05/opengraph-02092021.png" /> <meta name="twitter:label1" content="Written by" /> <meta name="twitter:data1" content="David Abraham" /> <meta name="twitter:label2" content="Est. reading time" /> <meta name="twitter:data2" content="1 minute" /> <script type="application/ld+json" class="aioseo-schema"> {"@context":"https:\/\/schema.org","@graph":[{"@type":"Article","@id":"https:\/\/wpforms.com\/templates\/medical-referral-form-template\/#article","name":"Customizable Medical Referral Form Template","headline":"Medical Referral Form Template","author":{"@id":"https:\/\/wpforms.com\/templates\/author\/dabrahamawesomemotive-com\/#author"},"publisher":{"@id":"https:\/\/wpforms.com\/templates\/#organization"},"image":{"@type":"ImageObject","url":"https:\/\/wpforms.com\/templates\/wp-content\/uploads\/2021\/05\/wpformslogo.png","@id":"https:\/\/wpforms.com\/templates\/#articleImage","width":549,"height":163},"datePublished":"2023-01-26T16:01:12-05:00","dateModified":"2023-12-05T23:52:20-05:00","inLanguage":"en-US","mainEntityOfPage":{"@id":"https:\/\/wpforms.com\/templates\/medical-referral-form-template\/#webpage"},"isPartOf":{"@id":"https:\/\/wpforms.com\/templates\/medical-referral-form-template\/#webpage"},"articleSection":"Business Operations, Health &amp; Wellness, Elite, Pro"},{"@type":"BreadcrumbList","@id":"https:\/\/wpforms.com\/templates\/medical-referral-form-template\/#breadcrumblist","itemListElement":[{"@type":"ListItem","@id":"https:\/\/wpforms.com\/templates\/#listItem","position":1,"name":"Home","item":"https:\/\/wpforms.com\/templates\/","nextItem":{"@type":"ListItem","@id":"https:\/\/wpforms.com\/templates\/medical-referral-form-template\/#listItem","name":"Medical Referral Form Template"}},{"@type":"ListItem","@id":"https:\/\/wpforms.com\/templates\/medical-referral-form-template\/#listItem","position":2,"name":"Medical Referral Form Template","previousItem":{"@type":"ListItem","@id":"https:\/\/wpforms.com\/templates\/#listItem","name":"Home"}}]},{"@type":"FAQPage","@id":"https:\/\/wpforms.com\/templates\/medical-referral-form-template\/#faq","url":"https:\/\/wpforms.com\/templates\/medical-referral-form-template\/","mainEntity":[{"@type":"Question","name":"How do I use WPForms form templates?","acceptedAnswer":{"@type":"Answer","text":"Our form templates are super easy to use. 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class="aioseo-breadcrumb"> Medical Referral Form Template </span></div> <header class="entry-header no-description"> <h1 class="entry-title title"> Medical Referral Form Template </h1> </header> <a href="https://wpforms.com/pricing/" class="button button-large" data-vars-ga-category="Templates Single" data-vars-ga-action="click" data-vars-ga-label="Use This Template (Bottom)">Use This Template</a> </div> </div> <div class="container single-container"> <div id="primary" class="site-content"> <main id="main" class="site-main" role="main"> <article class="post-5916 post type-post status-publish format-standard hentry category-business-operations category-health-wellness license-elite license-pro"> <div class="entry-content"> <div class="content-wpform-shortcode"> <div> <div class="wpforms-container wpforms-container-full form-template-disabled wpforms-container-save-resume wpforms-render-modern" id="wpforms-5915"><form id="wpforms-form-5915" class="wpforms-validate wpforms-form wpforms-ajax-form" data-formid="5915" method="post" enctype="multipart/form-data" action="/templates/medical-referral-form-template/" data-token="fa7850636f0f37b7443285fffe7b85fa" data-token-time="1740005416"><noscript class="wpforms-error-noscript">Please enable JavaScript in your browser to complete this form.</noscript><div class="wpforms-hidden" id="wpforms-error-noscript">Please enable JavaScript in your browser to complete this form.</div><div class="wpforms-field-container"><div id="wpforms-5915-field_3-container" class="wpforms-field wpforms-field-name" data-field-type="name" data-field-id="3"><label class="wpforms-field-label" for="wpforms-5915-field_3">Referring Hospital/Clinic <span class="wpforms-required-label" aria-hidden="true">*</span></label><input type="text" id="wpforms-5915-field_3" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][3]" aria-errormessage="wpforms-5915-field_3-error" required></div><div id="wpforms-5915-field_4-container" class="wpforms-field wpforms-field-layout" data-field-type="layout" data-field-id="4"><div class="wpforms-field-layout-columns wpforms-field-layout-preset-50-50"><div class="wpforms-layout-column wpforms-layout-column-50" ><div id="wpforms-5915-field_5-container" class="wpforms-field wpforms-field-phone" data-field-type="phone" data-field-id="5"><label class="wpforms-field-label" for="wpforms-5915-field_5">Phone <span class="wpforms-required-label" aria-hidden="true">*</span></label><input type="tel" id="wpforms-5915-field_5" class="wpforms-field-medium wpforms-field-required wpforms-smart-phone-field" data-rule-smart-phone-field="true" name="wpforms[fields][5]" aria-label="Phone" aria-errormessage="wpforms-5915-field_5-error" required></div><div id="wpforms-5915-field_7-container" class="wpforms-field wpforms-field-address" data-field-type="address" data-field-id="7"><fieldset><legend class="wpforms-field-label">Address <span class="wpforms-required-label" aria-hidden="true">*</span></legend><div class="wpforms-field-row wpforms-field-medium"><div ><input type="text" id="wpforms-5915-field_7" class="wpforms-field-address-address1 wpforms-field-required" name="wpforms[fields][7][address1]" aria-errormessage="wpforms-5915-field_7-error" required><label for="wpforms-5915-field_7" class="wpforms-field-sublabel after">Address Line 1</label></div></div><div class="wpforms-field-row wpforms-field-medium"><div ><input type="text" id="wpforms-5915-field_7-address2" class="wpforms-field-address-address2" name="wpforms[fields][7][address2]" aria-errormessage="wpforms-5915-field_7-address2-error" ><label for="wpforms-5915-field_7-address2" class="wpforms-field-sublabel after">Address Line 2</label></div></div><div class="wpforms-field-row wpforms-field-medium"><div class="wpforms-field-row-block wpforms-one-half wpforms-first"><input type="text" id="wpforms-5915-field_7-city" class="wpforms-field-address-city wpforms-field-required" name="wpforms[fields][7][city]" aria-errormessage="wpforms-5915-field_7-city-error" required><label for="wpforms-5915-field_7-city" class="wpforms-field-sublabel after">City</label></div><div class="wpforms-field-row-block wpforms-one-half"><select id="wpforms-5915-field_7-state" class="wpforms-field-address-state wpforms-field-required" name="wpforms[fields][7][state]" aria-errormessage="wpforms-5915-field_7-state-error" required><option class="placeholder" value="" selected disabled>--- Select state ---</option><option value="AL" >Alabama</option><option value="AK" >Alaska</option><option value="AZ" >Arizona</option><option value="AR" >Arkansas</option><option value="CA" >California</option><option value="CO" >Colorado</option><option value="CT" >Connecticut</option><option value="DE" >Delaware</option><option value="DC" >District of Columbia</option><option value="FL" >Florida</option><option value="GA" >Georgia</option><option value="HI" >Hawaii</option><option value="ID" >Idaho</option><option value="IL" >Illinois</option><option value="IN" >Indiana</option><option value="IA" >Iowa</option><option value="KS" >Kansas</option><option value="KY" >Kentucky</option><option value="LA" >Louisiana</option><option value="ME" >Maine</option><option value="MD" >Maryland</option><option value="MA" >Massachusetts</option><option value="MI" >Michigan</option><option value="MN" >Minnesota</option><option value="MS" >Mississippi</option><option value="MO" >Missouri</option><option value="MT" >Montana</option><option value="NE" >Nebraska</option><option value="NV" >Nevada</option><option value="NH" >New Hampshire</option><option value="NJ" >New Jersey</option><option value="NM" >New Mexico</option><option value="NY" >New York</option><option value="NC" >North Carolina</option><option value="ND" >North Dakota</option><option value="OH" >Ohio</option><option value="OK" >Oklahoma</option><option value="OR" >Oregon</option><option value="PA" >Pennsylvania</option><option value="RI" >Rhode Island</option><option value="SC" >South Carolina</option><option value="SD" >South Dakota</option><option value="TN" >Tennessee</option><option value="TX" >Texas</option><option value="UT" >Utah</option><option value="VT" >Vermont</option><option value="VA" >Virginia</option><option value="WA" >Washington</option><option value="WV" >West Virginia</option><option value="WI" >Wisconsin</option><option value="WY" >Wyoming</option></select><label for="wpforms-5915-field_7-state" class="wpforms-field-sublabel after">State</label></div></div><div class="wpforms-field-row wpforms-field-medium"><div class="wpforms-field-row-block wpforms-one-half wpforms-first"><input type="text" id="wpforms-5915-field_7-postal" class="wpforms-field-address-postal wpforms-field-required wpforms-masked-input" data-inputmask-mask="(99999)|(99999-9999)" data-inputmask-keepstatic="true" data-rule-inputmask-incomplete="1" name="wpforms[fields][7][postal]" aria-errormessage="wpforms-5915-field_7-postal-error" required><label for="wpforms-5915-field_7-postal" class="wpforms-field-sublabel after">Zip Code</label></div></div></fieldset></div></div><div class="wpforms-layout-column wpforms-layout-column-50" ><div id="wpforms-5915-field_6-container" class="wpforms-field wpforms-field-email" data-field-type="email" data-field-id="6"><label class="wpforms-field-label" for="wpforms-5915-field_6">Email <span class="wpforms-required-label" aria-hidden="true">*</span></label><input type="email" id="wpforms-5915-field_6" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][6]" spellcheck="false" aria-errormessage="wpforms-5915-field_6-error" required></div></div></div></div><div id="wpforms-5915-field_0-container" class="wpforms-field wpforms-field-name" data-field-type="name" data-field-id="0"><fieldset><legend class="wpforms-field-label">Referring Doctor <span class="wpforms-required-label" aria-hidden="true">*</span></legend><div class="wpforms-field-row wpforms-field-medium"><div class="wpforms-field-row-block wpforms-first wpforms-one-half"><input type="text" id="wpforms-5915-field_0" class="wpforms-field-name-first wpforms-field-required" name="wpforms[fields][0][first]" aria-errormessage="wpforms-5915-field_0-error" required><label for="wpforms-5915-field_0" class="wpforms-field-sublabel after">First</label></div><div class="wpforms-field-row-block wpforms-one-half"><input type="text" id="wpforms-5915-field_0-last" class="wpforms-field-name-last wpforms-field-required" name="wpforms[fields][0][last]" aria-errormessage="wpforms-5915-field_0-last-error" required><label for="wpforms-5915-field_0-last" class="wpforms-field-sublabel after">Last</label></div></div></fieldset></div><div id="wpforms-5915-field_18-container" class="wpforms-field wpforms-field-layout" data-field-type="layout" data-field-id="18"><div class="wpforms-field-layout-columns wpforms-field-layout-preset-50-50"><div class="wpforms-layout-column wpforms-layout-column-50" ><div id="wpforms-5915-field_1-container" class="wpforms-field wpforms-field-email" data-field-type="email" data-field-id="1"><label class="wpforms-field-label" for="wpforms-5915-field_1">Email <span class="wpforms-required-label" aria-hidden="true">*</span></label><input type="email" id="wpforms-5915-field_1" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][1]" spellcheck="false" aria-errormessage="wpforms-5915-field_1-error" required></div></div><div class="wpforms-layout-column wpforms-layout-column-50" ><div id="wpforms-5915-field_19-container" class="wpforms-field wpforms-field-phone" data-field-type="phone" data-field-id="19"><label class="wpforms-field-label" for="wpforms-5915-field_19">Phone <span class="wpforms-required-label" aria-hidden="true">*</span></label><input type="tel" id="wpforms-5915-field_19" class="wpforms-field-medium wpforms-field-required wpforms-smart-phone-field" data-rule-smart-phone-field="true" name="wpforms[fields][19]" aria-label="Phone" aria-errormessage="wpforms-5915-field_19-error" required></div></div></div></div><div id="wpforms-5915-field_8-container" class="wpforms-field wpforms-field-name" data-field-type="name" data-field-id="8"><fieldset><legend class="wpforms-field-label">Patient <span class="wpforms-required-label" aria-hidden="true">*</span></legend><div class="wpforms-field-row wpforms-field-medium"><div class="wpforms-field-row-block wpforms-first wpforms-one-half"><input type="text" id="wpforms-5915-field_8" class="wpforms-field-name-first wpforms-field-required" name="wpforms[fields][8][first]" aria-errormessage="wpforms-5915-field_8-error" required><label for="wpforms-5915-field_8" class="wpforms-field-sublabel after">First</label></div><div class="wpforms-field-row-block wpforms-one-half"><input type="text" id="wpforms-5915-field_8-last" class="wpforms-field-name-last wpforms-field-required" name="wpforms[fields][8][last]" aria-errormessage="wpforms-5915-field_8-last-error" required><label for="wpforms-5915-field_8-last" class="wpforms-field-sublabel after">Last</label></div></div></fieldset></div><div id="wpforms-5915-field_20-container" class="wpforms-field wpforms-field-layout" data-field-type="layout" data-field-id="20"><div class="wpforms-field-layout-columns wpforms-field-layout-preset-50-50"><div class="wpforms-layout-column wpforms-layout-column-50" ><div id="wpforms-5915-field_22-container" class="wpforms-field wpforms-field-email" data-field-type="email" data-field-id="22"><label class="wpforms-field-label" for="wpforms-5915-field_22">Email <span class="wpforms-required-label" aria-hidden="true">*</span></label><input type="email" id="wpforms-5915-field_22" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][22]" spellcheck="false" aria-errormessage="wpforms-5915-field_22-error" required></div></div><div class="wpforms-layout-column wpforms-layout-column-50" ><div id="wpforms-5915-field_21-container" class="wpforms-field wpforms-field-phone" data-field-type="phone" data-field-id="21"><label class="wpforms-field-label" for="wpforms-5915-field_21">Phone <span class="wpforms-required-label" aria-hidden="true">*</span></label><input type="tel" id="wpforms-5915-field_21" class="wpforms-field-medium wpforms-field-required wpforms-smart-phone-field" data-rule-smart-phone-field="true" name="wpforms[fields][21]" aria-label="Phone" aria-errormessage="wpforms-5915-field_21-error" required></div></div></div></div><div id="wpforms-5915-field_23-container" class="wpforms-field wpforms-field-address" data-field-type="address" data-field-id="23"><fieldset><legend class="wpforms-field-label">Address <span class="wpforms-required-label" aria-hidden="true">*</span></legend><div class="wpforms-field-row wpforms-field-medium"><div ><input type="text" id="wpforms-5915-field_23" class="wpforms-field-address-address1 wpforms-field-required" name="wpforms[fields][23][address1]" aria-errormessage="wpforms-5915-field_23-error" required><label for="wpforms-5915-field_23" class="wpforms-field-sublabel after">Address Line 1</label></div></div><div class="wpforms-field-row wpforms-field-medium"><div ><input type="text" id="wpforms-5915-field_23-address2" class="wpforms-field-address-address2" name="wpforms[fields][23][address2]" aria-errormessage="wpforms-5915-field_23-address2-error" ><label for="wpforms-5915-field_23-address2" class="wpforms-field-sublabel after">Address Line 2</label></div></div><div class="wpforms-field-row wpforms-field-medium"><div class="wpforms-field-row-block wpforms-one-half wpforms-first"><input type="text" id="wpforms-5915-field_23-city" class="wpforms-field-address-city wpforms-field-required" name="wpforms[fields][23][city]" aria-errormessage="wpforms-5915-field_23-city-error" required><label for="wpforms-5915-field_23-city" class="wpforms-field-sublabel after">City</label></div><div class="wpforms-field-row-block wpforms-one-half"><select id="wpforms-5915-field_23-state" class="wpforms-field-address-state wpforms-field-required" name="wpforms[fields][23][state]" aria-errormessage="wpforms-5915-field_23-state-error" required><option class="placeholder" value="" selected disabled>--- Select state ---</option><option value="AL" >Alabama</option><option value="AK" >Alaska</option><option value="AZ" >Arizona</option><option value="AR" >Arkansas</option><option value="CA" >California</option><option value="CO" >Colorado</option><option value="CT" >Connecticut</option><option value="DE" >Delaware</option><option value="DC" >District of Columbia</option><option value="FL" >Florida</option><option value="GA" >Georgia</option><option value="HI" >Hawaii</option><option value="ID" >Idaho</option><option value="IL" >Illinois</option><option value="IN" >Indiana</option><option value="IA" >Iowa</option><option value="KS" >Kansas</option><option value="KY" >Kentucky</option><option value="LA" >Louisiana</option><option value="ME" >Maine</option><option value="MD" >Maryland</option><option value="MA" >Massachusetts</option><option value="MI" >Michigan</option><option value="MN" >Minnesota</option><option value="MS" >Mississippi</option><option value="MO" >Missouri</option><option value="MT" >Montana</option><option value="NE" >Nebraska</option><option value="NV" >Nevada</option><option value="NH" >New Hampshire</option><option value="NJ" >New Jersey</option><option value="NM" >New Mexico</option><option value="NY" >New York</option><option value="NC" >North Carolina</option><option value="ND" >North Dakota</option><option value="OH" >Ohio</option><option value="OK" >Oklahoma</option><option value="OR" >Oregon</option><option value="PA" >Pennsylvania</option><option value="RI" >Rhode Island</option><option value="SC" >South Carolina</option><option value="SD" >South Dakota</option><option value="TN" >Tennessee</option><option value="TX" >Texas</option><option value="UT" >Utah</option><option value="VT" >Vermont</option><option value="VA" >Virginia</option><option value="WA" >Washington</option><option value="WV" >West Virginia</option><option value="WI" >Wisconsin</option><option value="WY" >Wyoming</option></select><label for="wpforms-5915-field_23-state" class="wpforms-field-sublabel after">State</label></div></div><div class="wpforms-field-row wpforms-field-medium"><div class="wpforms-field-row-block wpforms-one-half wpforms-first"><input type="text" id="wpforms-5915-field_23-postal" class="wpforms-field-address-postal wpforms-field-required wpforms-masked-input" data-inputmask-mask="(99999)|(99999-9999)" data-inputmask-keepstatic="true" data-rule-inputmask-incomplete="1" name="wpforms[fields][23][postal]" aria-errormessage="wpforms-5915-field_23-postal-error" required><label for="wpforms-5915-field_23-postal" class="wpforms-field-sublabel after">Zip Code</label></div></div></fieldset></div><div id="wpforms-5915-field_2-container" class="wpforms-field wpforms-field-textarea" data-field-type="textarea" data-field-id="2"><label class="wpforms-field-label" for="wpforms-5915-field_2">Medical History <span class="wpforms-required-label" aria-hidden="true">*</span></label><textarea id="wpforms-5915-field_2" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][2]" aria-errormessage="wpforms-5915-field_2-error" required></textarea></div><div id="wpforms-5915-field_15-container" class="wpforms-field wpforms-field-textarea" data-field-type="textarea" data-field-id="15"><label class="wpforms-field-label" for="wpforms-5915-field_15">Family Medical History <span class="wpforms-required-label" aria-hidden="true">*</span></label><textarea id="wpforms-5915-field_15" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][15]" aria-errormessage="wpforms-5915-field_15-error" required></textarea></div><div id="wpforms-5915-field_14-container" class="wpforms-field wpforms-field-textarea" data-field-type="textarea" data-field-id="14"><label class="wpforms-field-label" for="wpforms-5915-field_14">Patient Symptoms <span class="wpforms-required-label" aria-hidden="true">*</span></label><textarea id="wpforms-5915-field_14" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][14]" aria-errormessage="wpforms-5915-field_14-error" required></textarea></div><div id="wpforms-5915-field_13-container" class="wpforms-field wpforms-field-textarea" data-field-type="textarea" data-field-id="13"><label class="wpforms-field-label" for="wpforms-5915-field_13">Tests Done <span class="wpforms-required-label" aria-hidden="true">*</span></label><textarea id="wpforms-5915-field_13" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][13]" aria-errormessage="wpforms-5915-field_13-error" required></textarea></div><div id="wpforms-5915-field_12-container" class="wpforms-field wpforms-field-textarea" data-field-type="textarea" data-field-id="12"><label class="wpforms-field-label" for="wpforms-5915-field_12">Referring Doctor Comments <span class="wpforms-required-label" aria-hidden="true">*</span></label><textarea id="wpforms-5915-field_12" class="wpforms-field-medium wpforms-field-required" name="wpforms[fields][12]" aria-errormessage="wpforms-5915-field_12-error" required></textarea></div><div id="wpforms-5915-field_24-container" class="wpforms-field wpforms-field-date-time" data-field-type="date-time" data-field-id="24"><label class="wpforms-field-label" for="wpforms-5915-field_24">Date <span class="wpforms-required-label" aria-hidden="true">*</span></label><div class="wpforms-datepicker-wrap"><input type="text" id="wpforms-5915-field_24" class="wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium" data-date-format="m/d/Y" data-disable-past-dates="0" data-input="true" name="wpforms[fields][24][date]" aria-errormessage="wpforms-5915-field_24-error" required><a title="Clear Date" data-clear class="wpforms-datepicker-clear" style="display:none;"></a></div></div><div id="wpforms-5915-field_16-container" class="wpforms-field wpforms-field-signature" data-field-type="signature" data-field-id="16"><label class="wpforms-field-label" for="wpforms-5915-field_16">Signature <span class="wpforms-required-label" aria-hidden="true">*</span></label><input type="text" id="wpforms-5915-field_16" class="wpforms-signature-input wpforms-screen-reader-element wpforms-field-required" data-is-wrapped-field="1" name="wpforms[fields][16]" autocomplete="off" aria-errormessage="wpforms-5915-field_16-error" required><div class="wpforms-signature-wrap wpforms-field-large"><canvas class="wpforms-signature-canvas" id="wpforms-5915-field_16-signature" data-color="#000000"></canvas><div class="wpforms-signature-clear" title="Clear Signature" tabindex="0"> <svg xmlns="http://www.w3.org/2000/svg" width="1em" height="1em" preserveAspectRatio="xMidYMid meet" viewBox="0 0 1536 1536"> <path fill="var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )" d="M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z"/> </svg> <div class="wpforms-signature-clear-caption">Clear Signature</div> </div></div></div></div><!-- .wpforms-field-container --><div class="wpforms-submit-container" ><input type="hidden" name="wpforms[id]" value="5915"><input type="hidden" name="page_title" value="Medical Referral Form Template"><input type="hidden" name="page_url" value="https://wpforms.com/templates/medical-referral-form-template/"><input type="hidden" name="page_id" value="5916"><input type="hidden" name="wpforms[post_id]" value="5916"><button type="submit" name="wpforms[submit]" id="wpforms-submit-5915" class="wpforms-submit" data-alt-text="Sending..." data-submit-text="Submit" aria-live="assertive" value="wpforms-submit">Submit</button><img src="https://wpforms.com/templates/wp-content/plugins/wpforms/assets/images/submit-spin.svg" class="wpforms-submit-spinner" style="display: none;" width="26" height="26" alt="Loading"></div></form></div> <!-- .wpforms-container --> <div class="block-required-plan block"> <div class="block-container"> <a href="https://wpforms.com/pricing/" class="plan-notice-box"> <div class="plan-badge-holder"> <span class="plan-badge">pro</span> </div> <span>This template includes features available in WPForms Pro. <span class="plan-compare">Compare Plans</span></span> </a> </div> </div> </div> </div> <div class="single-template-content"> <p>Do you run a hospital or clinic? From time to time, other doctors and hospitals will refer a patient to yours. When this happens, you&#8217;ll need some background information on the patient. Medical referral forms help to collect much of the information you&#8217;ll need. If you&#8217;d like to get started with a template, this WPForms&#8217; Medical Referral Form Template would be perfect!</p> <p>When patients are referred between medical facilities, it&#8217;s really important to ensure that all the relevant data is properly communicated from the referring doctor to the receiving one. This is important to help the receiving doctors make informed diagnoses.</p> <p>The WPForms&#8217; Medical Referral Form Template does this really well by using a mix of form fields. First, the template offers a single-line text field to capture the referring hospital&#8217;s name. This is accompanied by the Email, Phone, and Address fields.</p> <p>The next section is nearly identical, as it uses similar fields to collect the referring doctor&#8217;s contact information. The rest of the template is dominated by paragraph text fields where referring doctors can provide notes on things like medical history, family medical history, their comments, and so on.</p> <p>Other than these, the Medical Referral Form Template has a date field and a signature field for the referring doctor to sign.</p> <p>Get started with WPForms today to create and customize your own medical referral form. Signing up with WPForms gives you access to this and hundreds of other pre-made templates.</p> </div> </div> </article> </main> </div> </div> <div class="container wpf-pro-cta"> <a href="https://wpforms.com/pricing/" class="button button-large" data-vars-ga-category="Templates Single" data-vars-ga-action="click" data-vars-ga-label="Get WPForms Pro (Bottom)">Get WPForms Pro</a> </div> <div class="related-templates-wrap"> <h2 class="title">Looking for something else?</h2> <p>Here are some other <a href="https://wpforms.com/templates/category/business-operations">Business Operations form templates</a></p> <div class="related-templates-grid templates-list"> <div class="template-demo-block "> <div class="thumb-template"> <a href="https://wpforms.com/templates/subscription-box-signup-form-template/"><img src="https://wpforms.com/templates/wp-content/uploads/templates/thumb/3d2509a101785d1fb0f4a7609cb9fdfe.jpg" alt="Subscription Box Signup Form Template"></a> </div> <div class="content"> 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