Physician Referral
Physician Referral
Tarrant Nephrology Associates Referral & Callback Service is offered for physicians of patients diagnosed with kidney disease who are interested in treatment offered at Tarrant Nephrology centers.
To refer a patient or receive a callback from our office, please complete the requested information below. You may also fax a referral directly to our new patient intake team at 817-882-9822.
Phone - 817-877-5858 and Fax - 817-882-9822 (Attn : New patient scheduling)
Referral Form
* Denotes Required Field
Physician Last Name: *
Physician Phone Number: *
Physician Fax Number: *
Office Contact Name: *
Office Contact Email: *
Patient First Name: *
Patient Last Name: *
Patient Phone Number: *
Patient DOB: *
Additional Patient Information
Patient Contact Info
Address:
City:
State:
Zip Code:
Email:
Diagnosis
Chronic Kidney Disease Stage 1
Chronic Kidney Disease Stage 2
Chronic Kidney Disease Stage 3
Chronic Kidney Disease Stage 4
Chronic Kidney Disease Stage 5
Anemia
Protinuria
Hypertension
ESRD
Renal Mass
Renal Cyst
Kidney Stones
Others
Patient Insurance Info
Carrier:
ID Number:
I am ready to refer the patient for an appointment.
Have your scheduling staff..
Call the patient directly with an appointment time.
Call my office contact with an appointment time.
Contact me with an appointment time
Further Instructions if Required:
