Physician Referral

To refer a patient for an appointment, please complete the form below and your patient will be contacted for scheduling. Fax referral forms may be sent to 303.270.2162.

You may also contact our Physician Line at 1.800.652.9555, Monday - Friday, 8:00 am to 5:00 pm Mountain Time or physicianline@njhealth.org.

For mycobacterial disease referrals, complete the Mycobacterial Referral/Consult form.

Other resources: COVID-19 Testing Referral | Order a test | General Physician Consults | Radiology Consult

Provider Information

Provider First Name

Provider Last Name

Name of Office

Provider Country

Provider Address

Provider Phone number

Patient Information

Patient First Name

Patient Last Name

Patient Gender

Female
Male
Transgender

Patient Date of Birth

Patient Age

Parent or Guardian's Name (if applicable)

Patient Country

Patient Address

Patient Phone Number

Have you previously contacted National Jewish Health about this patient?

Specialty Requested

Reason for Visit

DX and Brief History
(Please include something in addition to the ICD9 code)

Medications