Refer a Patient to MUSC

To refer a patient to an MUSC physician, please complete the referral form below. Please attach documents as needed. An MUSC representative will contact you within one business day regarding your request.
Fields marked with "«" are required.
Patient Information
Patient First Name«
Patient Middle Initial:
Patient Last Name«
Date of Birth« (format:mm/dd/yyyy)
Patient Gender «	FemaleMale
Address 1«
Address 2:
City«
State«
Zip«
Phone Number (000-000-0000) «	CellHomeOffice
If patient is a minor, parent or guardian:
First Name:
Middle Initial:
Last Name:
Appointment Information
Insurance Information «
Who is the patient's family doctor?
Type of doctor patient would like to see«
Name of MUSC physician patient would like to see:	Look Up
Has patient seen this physician before?«
Referring physician name«	Look Up (Select a physician from Look Up to auto-populate the referring address, phone and fax fields)
Referring physician e-mail«
Referring Physician Practice Name:
Referring physician address«
City«
State«
Zip code«
Referring physician phone number«
Referring physician fax:
Referring physician specialty:
Reason For Appointment« (diagnosis, symptoms, additional information etc.)
Name of contact at physician's office «
Phone number of contact «	Ext.
Preferred location:	Look Up Note: Not all physicians see patients in all locations
Preferred day:	MonTueWedThuFri
Preferred time:	Any timeEarly AMLate AMEarly PMLate PM
If you are not able to attach electronic documents, check the “Fax Documents” box.
Fax Documents:
If you are able to attach electronic documents, click the “Attach Documents” link below.
Attach Documents Please attach only Word (.doc), Acrobat (.pdf) and Excel (.xls) documents.


SSL Certificate
Is my personal information safe to send to you by the internet?