For referring physicians

Medical referrals

A clear circuit for referring patients to SAH, with follow-up at every stage.

How the circuit works

Through the form on this page, attaching the medical order and any available prior studies.

The information received is reviewed to determine the indicated procedure.

Date and time coordination is handled together with the corresponding clinic. This site does not grant appointments directly.

The patient is contacted with the confirmed date and preparation instructions.

When applicable, the referring physician is informed.

Filling out this form does not assign or confirm an appointment. Final date and time scheduling is coordinated with the corresponding clinic.

Fields marked with * are required.

Patient information

Patient's full name *

ID number *

Date of birth *

Phone *

City / Town *

Health insurance / coverage

Referring physician's information

Physician's full name *

Medical license number *

Physician's phone *

Physician's email *

Reason for the referral

Reason for the referral *

Priority level *

Medical order Accepted formats: PDF, JPG or PNG.

Prior studies You can attach more than one file.

Notes

I give my consent for the processing of the personal and health data included in this form, in accordance with SAH's Health Data Processing Policy. *