Catalina Pediatrics Web Site
Request a Specialist Referral

Use this form to request a referral to see a specialist.  In general, we prefer that you speak to your pediatrician about your child's problem before seeking a referral to a specialist.  Many insurance companies require this.  Also, we can take care of many illnesses at our office instead of sending your child to a specialist, and this is usually much faster and more convenient for you.  So please call us if you haven't already spoken to us about the problem.  If you have spoken to your pediatrician about your child's illness and have been advised to see a specialist, or if you have already seen the specialist and need a referral for a follow-up appointment, then use this page to send us your request.  

Please do not use this form if you already have an appointment scheduled to see the specialist in the next couple of days and need the referral done today.  We need at least 2 business days to respond to your request (even longer with some insurance companies).  When you submit the form, you will see a confirmation page indicating what you have requested.  If any information is incorrect, then come back to this form and try again.  Once we generate your referral, we will email you with the referral information.  Make sure your contact information is correct in case we need to call you for more information in order to generate the referral.

Before using any of the email functions, please read our Email Disclaimer.


Your Name:  

Patient's Name:  

Patient's Date of Birth:  

Your E-mail Address:  

Phone Number (indicate the phone number or numbers where you can most easily be reached):

Who is your pediatrician? 

What is your insurance company? 

What kind of specialist (i.e. dermatologist, orthopedist)? 

What is the specialist's name (if you don't have a specific doctor in mind and you would like us to choose one that is on your insurance plan then leave it as "I don't know")?

What is the diagnosis (if you don't know, then describe the problem)?

What kind of appointment? 

If you already have an appointment scheduled, indicate the date and time below.

Date:      Time: 

Any special requests or other information?

           

Date this page was last changed:  10/28/2007

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