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Wyoming Only Physician Referrals

Referrals

It’s safe and easy to refer your patients to Rocky Mountain Infectious Diseases! Just fill out the secure form with the basics, and our office staff will get in touch with your office staff to transfer any needed patient files.

Step 1 of 4 - Referring Physician

Are you a registered physician looking to refer one of your patients?
- Yes
- No
This form is for physicians only. If you would like to schedule an appointment for yourself, please call our office at (307) 234-8700.

Referring Physician Name*
First Last
Email
Enter Email Confirm Email
Phone*
Fax*
Clinic Name*
Clinic Address*
Street Address Address Line 2 City State ZIP Code

Patient Name*
First Last
Date of Birth*
Phone*
Reason for Referral*

Attach Records
Drop files here or

Accepted file types: pdf, jpg, png, doc, Max. file size: 8 MB.
Please fax records (History and Physical; Labs; Cultures; Radiography; Medication List) to 307-234-8750 or attach files here.
Comments or Notes
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