Refer a Patient

Our expert doctors and specialists value our referring doctor partnerships. We are committed and passionate about providing exceptional ENT care for your patients impacted by ENT-related issues.

We want to make the referral process easy, so choose the best option for your team.

Refer by Phone or Fax Refer Online

Refer by Phone or Fax

Hamden

203.248.8409

Fax: 203.281.2905

9 Washington Avenue, Floor 3
Hamden, CT 06518

Madison

203.245.5899

141 Durham Road, Suites 3-21
Madison, CT 06443

Milford

203.876.1159

849 Boston Post Road, Suite 202
Milford, CT 06460

Thank you for trusting us with your patient’s care. Together, we are dedicated to ensuring that each person’s unique needs are addressed so they can experience life to the fullest.

Referral Form

"*" indicates required fields

Physician*

Patient First Name*

Patient Last Name*

Date of Birth*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Email*

Reason for Consultation

Urgency for Referral

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Preferred Provider

Write In

First Available Provider

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Preferred Provider (write-in)

Additional Notes and Special Needs

e.g., wheelchair, interpreter, etc.

Referring Doctor First Name*

Referring Doctor Last Name*

Referring Doctor Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Practice Phone*

Practice Email*

Practice Fax

Email

This field is for validation purposes and should be left unchanged.