Referral Process and Forms
Medically Urgent Referrals
Call the Referral Center directly at (800) 995-5724.
Requested information should then be faxed to (650) 721-2884.
All Other Outpatient Referrals
Please provide the following for outpatient referrals:
- Stanford Children’s Health Referral Request Form or the form is also available on the MD Portal
- Relevant notes
- Copy of patient’s insurance card
- Authorization for Treatment (if required by insurance provider)
Fax all forms to (650) 721-2884 or submit electronically via mdportal.stanfordchildrens.org
Outpatient Specialty Referrals
The following services require specific referral forms and/or clinical notes:
- General out-patient referral form
- Audiology referral request form
- Center for Fetal and Maternal Health, referring physician orders
- Developmental-behavioral pediatrics, referral form, Please include growth chart
- ECG, Echo, Holter monitor or event request recorder
- EEG - outpatient orders form
- Endocrinology, Please include pertinent labs, growth chart and notes from last 3 visits.
- Exercise Laborator orders form
- Fetal Echocardiogram orders form
- Genetics referral request form, Please include growth chart.
- Hematology, Please make direct referral by calling (650) 497-8953.
- Infectious Disease, Please include immunization records.
- Motion & Gait referral request form
- Nephrology Please include pertinent labs.
- Neurolog referral request form
- Neuro-Oncology, Please make direct referral by calling (650) 497-8953.
- Neurosurgery, Please include pertinent labs, MRIs and/or CTs
- Nuclear Medicine referral request form
- Oncology, Please make direct referral by calling (650) 497-8953.
- Pain Management referral request form
- Perinatal Diagnostic Center (PDC) referral request form
- Pulmonary Clinic referral request form
- Radiology requisition form
- Rehabilitation Service request referral form
- Sleep Clinic referral request form
- Urology, Please include pertinent labs and radiology reports
- Weight Clinic/ Weight Control Program referral request form, Please include growth chart
For information about services not listed, call the Stanford Children’s Health Physician Referral Center
Monday – Friday
7:00am – 6:00pm