Physician Referral Form

Securely request an expert second opinion for your patient. Please complete all required fields marked with an asterisk (*).

PHIPA & PIPEDA Compliant

Patient Demographics

First Name *Last Name *Date of Birth *Health Card Number (HCN) *Phone NumberEmail Address

Referring Provider

Provider First Name *Provider Last Name *Billing / MSP Number *Required for verificationEmail Address *We'll send your confirmation hereClinic Name

Report Delivery Preferences *

Choose how you'd like to receive the final report. You can select both.

Email ReportFax Report

Send report to *Pre-filled from the email above — edit if reports should go elsewhere.

Clinical Details

Priority Level *

UrgentHighest prioritySemi-UrgentElevated priorityRoutineStandard priority

Reason for Referral / Clinical History *Imaging Info (Optional)Upload Reports & Imaging (Optional)

Click to upload or drag and drop

PDF, DICOM, JPG or PNG (Max 50MB)

Email Patient an Upload Link

Only enable this if you know the patient has access to their own DICOM files. The patient will receive a secure, branded link to upload their imaging directly to Radiology Experts.

Email the patient a secure upload link automatically on submitPatient's emailPre-filled from the email above — change it to the patient's own email.

Physician Referral Form

Patient Demographics

Referring Provider

Clinical Details

Email Patient an Upload Link

For Patients

For Physicians

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