Consult Clinic Guidelines and Referral Form021517 docx 2026

1. Click ‘Get Form’ to open the Consult Clinic Guidelines and Referral Form021517 in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's last name, first name, age, date of birth, and home address. Ensure all details are accurate for proper identification.
3. Indicate whether the patient is new to Texas Children’s by selecting 'YES' or 'NO'. If applicable, provide the TCH Medical Record Number.
4. Complete the 'Parent/Guardian Information' section with relevant contact details including names and phone numbers. Specify if an interpreter is needed and what language.
5. In the 'Referring Physician Contact Information' section, fill in the physician's name, email address, mailing address, and contact numbers to ensure seamless communication.
6. Detail any significant medical history in the provided fields. This includes reasons for referral, health problems, surgical procedures, allergies, and family history.
7. Once completed, review all entries for accuracy before submitting your form via fax to 713-396-1995 as instructed at the bottom of the document.

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