Memorial Northwest Otolaryngology

Refer a Patient
Please fill out the following information to refer a new patient. For STAT requests, please call the office at 713.802.9779. Please note that this feature is for qualified physicians only. Thank you

Full Name of Patient:
Patient’s DOB:
Patient Status:	Outpatient Inpatient
Reason for Consultation:




Preferred Physician:
Full Name of Referring Physician:
Phone of Referring Physician:
Fax of Referring Physician:
Email of Referring Physician:
How soon would you like the patient seen?
Does the patient need a hearing test?	Yes No Not sure
Preferred form of feedback on the patient:



We are not Medicaid providers