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Loma Linda University Health Care Physician Referral Form

This form is to be used for physician referral only. For all other questions or comments consult our contact information page. To contact physician referral by phone, call (800) 872-1212.

This form should NOT be used for urgent requests. If you have an emergency situation, call 911 or go to your local emergency room.

 

Your name
Date of birth      male  female
Address
City        State        ZIP 
Home phone       Office phone      
FAX
Email address (required)
Type of insurance
   


Type of physician needed:

OB/GYN
Family practice
Pediatrician
Internal medicine
Specialist
Other: 


If specialist, choose type:

 

Cardiology (heart)
Pediatrician (children's specialist)
Dermatologist (skin/hair/nails)
Ophthalmologist (eye/vision)
Orthopaedics (bone/joint)
Otolaryngologist (ear/nose/throat)
Physical medicine & rehabilitation specialist
Surgery
Other: 
 


This form should NOT be used for urgent requests. If you have an emergency situation, call 911 or go to your local emergency room.



Direct questions/comments about this form to .