Patient Referral Submission

Patient Referral Submission

Upload Demographics/Face Sheet, Insurance Card (if available), Labs, Imaging, Diagnostic Reports, and Procedures pertaining to DX for this patient.
Clinic Info

Address: 1411 North Beckley Ave., Pavilion III, Ste. 268, Dallas, TX 75203
Phone: (214) 947-4400
Referral Fax: (214) 947-4446
Email: MDMC_Transplant@mhd.com
Referring Provider Info
Referring Provider Name*
Office Name
Office Phone*
Office Fax
Additional Contact Info:
Requested services: (check all that apply)

Expedited Consult: Carcinoma, Mass, Liver FailureRequest for Liver Transplant Evaluation(Performed at Dallas Location-Only)Non-Emergent Consultation / Opinion / Assume Patient Care
Diagnosis (required)*
Is this referral for:

HepatologySurgeryInfectious Disease
Preferred Location

Amarillo (Habib/Mantry/Nazario)Bedford (Weinstein)Dallas (All)Fort Worth (Habib/Nazario/Mehta)Lubbock (Barnes/Mantry/Weinstein)Mansfield (Habib/Pagadala)McKinney (Barnes/Griffin)Midlothian (Habib/Mehta)Midland (Pagadala)Plano (Barnes/Mantry/Nazario)Richardson (Griffin/Mantry)Tyler (Barnes/Mantry/Mehta/Pagadala)Southlake (Mehta/Weinstein)
Patient Information
Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
Date
Patient Phone Number*
Please enter a valid phone number.
Patient Email
example@example.com
File Upload

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Referring Provider Info