Refer a patient
To refer your patient, please provide the information requested below. This is a secure form and the information you provide will enable us to assist your patient as efficiently as possible.
A representative of the VCU Health Patient Appointment Center will contact the patient within 1-2 business days to help schedule an appointment.
If you are referring a patient under the age of 18, please use our pediatric patient referral form.
For Massey Cancer Center, please use our refer a patient form.
If you are a patient, please use our appointment request form.
*Denotes required field
Patient information
Patient first name: *
Patient last name: *
Date of birth (mm/dd/yyyy): *
Email: *
Phone (xxx-xxx-xxxx): *
Please select the patients preferred language: *
Insurance type: *
Medical information
Please select the appropriate adult specialty: *
Diagnosis: *
Preferred provider:
Additional information: (please include the level of urgency)
Referring provider office information
Referring provider title:
Referring provider first name: *
Referring provider last name: *
Provider NPI number:
Practice name: *
Practice NPI number:
Office contact information (name of the person to contact if there are questions about this referral)
Office contact first name:
Office contact last name:
Office contact phone (xxx-xxx-xxxx): *
Office contact email: (your email will only be used to confirm that we have received your appointment request) *
Office fax (xxx-xxx-xxxx):