Customize template

Use this doctor referral form in your practice to collect patient and referring doctor details, such as contact info, medical history, and even digital signatures. Of course, once you’ve copied this pre-made template into your 123FormBuilder account, there’s no limit to what you can add to it. Use the drag and drop to add more fields, upload your logo, change the form theme and configure multiple email recipients.

Publish template

After retouching the content and appearance of your doctor referral form, you’ll want it made available for fellow healthcare practitioners. To this end, you only need to copy and paste the form code to embed it on a web page. Alternatively, the form link travels well on email or other web platforms – our system provides you with many options to choose from. Furthermore, with the mobile responsive form design, the doctor referral form will look good on any screen size.

Collect & manage data

Every doctor referral you receive lands in a secure database. We take data protection seriously, and you can even get HIPAA compliance on your forms with just a few clicks. Analyze and update your data table directly in the 123FormBuilder dashboard or export it to Excel, CSV or PDF. In addition, if you like using a file management app to enhance record keeping, make sure you check out our multiple third-party integrations.

Optimize your flow

Simplify patient record keeping with online forms that do so much more than just accumulate information. With 123FormBuilder it’s easy to configure just the medical form you need, without having to write any code. Besides, with instant email or SMS alerts each time a new submission comes in, you’ll save precious time.

Are you looking for a different template?

We have more form templates to choose from