LLU Children's Hospital physician referral

This form is to be used for physician referral only. For all other questions or comments consult our contact information page.

To contact physician referral by phone, call (800) 872-1212.

This form should NOT be used for urgent requests. If you have an emergency situation, call 911 or go to your local emergency room.

Your name
Date of birth	male female
Address
City	State ZIP
Home phone	Office phone
FAX
Email address	(required)
Type of insurance

Type of physician needed:	OB/GYN Family practice Pediatrician Internal medicine Specialist Other:
If specialist, choose type:	Cardiology (heart) Pediatrician (children's specialist) Dermatologist (skin/hair/nails) Ophthalmologist (eye/vision) Orthopaedics (bone/joint) Otolaryngologist (ear/nose/throat) Physical medicine & rehabilitation specialist Surgery Other:
	This form should NOT be used for urgent requests. If you have an emergency situation, call 911 or go to your local emergency room. Direct questions/comments about this form to webmaster@llu.edu.