Refer a Patient | Patient Consult: 214-838-6440

Refer a Patient


Thank you for your patient referral to Fibroid Institute Dallas

 

Providers: Please complete the form below. If you prefer to instead download a PDF version, please click here: 

FOR ALL REFERRALS, PLEASE SEND IN:

  • Demographics
  • Insurance information
  • History, physical and most recent note
  • U/S report and EMB results (if available)

    **We will order MRI if you have not.
  • Drop files here or
    Accepted file types: pdf, jpg, gif, png, zip.
    For multiple files, please put them in one folder and zip the folder. Then upload the zip file. The maximum file size is 2 MB.
  • This field is for validation purposes and should be left unchanged.