Neurosurgery Physician Referral Form

The COVID-19 health crisis has affected clinic operations throughout UK HealthCare. See our information for referring providers.

Refer a patient to Neurosurgery

Patients must be referred through their primary care provider or specialist. Please send, along with the referral form above, office notes, any additional imaging (MRI/CT/X-ray) that correlate with the referred diagnoses, and a list of current medications. Please instruct patient to arrive at least 20 minutes before their appointment in order to get registered. Please instruct patient bring your imaging on disc to the appointment and all necessary paperwork. This will assist in ensuring prompt service and visitation with their physician.

Thank you for your referral to UK Neurosurgery. We will review your patient’s records and contact you as quickly as possible. Please provide us with the clinical and demographic information we need for review. The Department of Neurosurgery does not require imaging to be completed within the past six months, but patients referred for spine conditions without imaging will be scheduled with a department PA / APRN for initial consult to order any additional imaging and testing on an as needed basis. Please fax recent office notes, history and physical, relevant radiologic study reports, copy of the patient’s insurance card to 859-323-6343 or 859-323-1330. These can also be attached as PDFs to the form below. If you have any questions, please contact our offices directly. In addition, please provide us with contact information for your office so that any missing information can be requested.

***Please note, physician requested may not always be the physician who sees the patient. This is based on urgency and each physician’s specialty.

Patient information

Patient information
This information is required to ensure the patient is scheduled with the proper physician.
Please attach the required documents listed at the top or fax them to 859-257-8902.
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
Patient pharmacy
Has the patient had past treatment for Pain Management?
Has the patient had past physical therapy?

Insurance Information

Workers's Compensation Information (If Applicable)

Referring Physician Information

Referring Physician
Please list name and direct contact phone number.

Primary Care Physician Information

Referring Physician
Please list name and direct contact phone number.
Refer To: