The Western Pennsylvania Hospital - Forbes Regional Campus Search:

To refer one of your patients, you may call us at 1-866-680-0004, or complete this form to begin the patient referral process. A representative in your office will be contacted by one of our Referral Specialists to collect additional information. The patient will be contacted and the appointment confirmed.

* Indicates a required field.

Information About The Referring Physician:
First name: *
Last name: *
Street address:
City:
State:
Zip:
Country:
Office phone: *
Office fax:
Email:
Information About The Patient:
First name: *
Last name: *
Date of birth (MM/DD/YYYY):
Gender: * Male Female
Street Address:
City:
State:
Zip:
Country:
Daytime phone: *
Evening phone:
Fax:
Diagnosis Information:
Diagnosis date (MM/DD/YYYY): *
Diagnosis method: Biopsy
Lab Work
CT Scan
MRI
Ultrasound
X-Ray
Cytology
Other (please specify):
  
General diagnosis information: *
Treatment Information
Is the patient currently under treatment? * Yes
No
Describe the method of treatment: *
Referral Information:
Are you referring to a specific physician? * Yes
No
Physician name:
(Click here to review our Clinical Staff Directory)
 

One of our Referral Specialists will call your office to discuss this referral further and to obtain additional information pertinent to this patient. Please indicate the contact person who can best assist with this referral.
Same as Physician information above?
First name:
Last name:
Contact title:
Daytime phone and extension:

Your patient will also be contacted in order to review insurance coverage and obtain additional demographic information. Medical and financial eligibility will need to be established prior to confirming an appointment. If you would like to leave a message for our referral office, please type it here:

All e-mail referral forms will receive a response within 24 hours excluding weekends and holidays. If you require immediate assistance, please call our referral office (Monday through Friday from 8:00 a.m. to 5:00 p.m. EST) at 1-866-680-0004.