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Neurosurgery Physician Referral Form

Use this form to refer a patient

Patients must be referred through their primary care provider or specialist. Please send, along with the referral form above, office notes, MRIs done within the past 6 months, and a list of current medications. Please arrive at least 20 minutes before your appointment in order to get registered. Please bring your MRI on disc to the appointment and all necessary paperwork. This will assist in ensuring prompt service and visitation with your 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 requires that all new patients have had imaging (MRI or CT only) in the past six months which demonstrates an abnormality. Please fax recent office notes, history and physical, relevant radiologic study reports, copy of the patient’s insurance card to 859-257-8902 or attach them to this form. If you have any questions, please contact our offices directly. Referrals will be denied if all of this information is not received (exception: movement disorders). ***Please note, physician requested may not be the physician who sees the patient. This is based on urgency and each physician’s specialty.

Patient information

This information is required to ensure the patient is scheduled with the proper physician.
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.
Please attach the required documents listed at the top or fax them to 859-257-8902.
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

Please list name and direct contact phone number.

Primary Care Physician Information

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