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Medically urgent referrals

• Submit directly to our MD Portal at
• If you are unable to submit directly to MD Portal, please fax to (650) 721-2884Ìý

All other outpatient referrals

Please provide the following for outpatient referrals:

1. Â鶹¹û¶³´«Ã½ Children’s Health Referral Request Form or the form is also available on the
2. Relevant notes
3. Copy of patient’s insurance card
4. Authorization for Treatment (if required by insurance provider)

Fax all forms to (650) 721-2884 or submit electronically via

Outpatient specialty referrals

The following services require specific referral forms and/or clinical notes:

• General out-patient referral form
• Audiology referral request form
• Center for Fetal and Maternal Health, referring physician orders
• Developmental-behavioral pediatrics, referral form, Please include growth chart
• Eating Disorders referral form
• ECG, Echo, Holter monitor or event request recorder
• EEG - outpatient referral form
• Endocrinology, Please include pertinent labs, growth chart and notes from last 3 visits.
• Exercise Laborator orders form
• Fetal Echocardiogram orders form
• Genetics referral request form, Please include growth chart.
• Hematology, Please make direct referral by calling (650) 497-8953.
• Infectious Disease, Please include immunization records.
• Motion Analysis and Sports Performance Laboratory referral form
• Motion & Gait referral request form
• Nephrology Please include pertinent labs.
• Neurology referral request form
• Neuro-Oncology, Please make direct referral by calling (650) 497-8953.
• Neurosurgery, Please include pertinent labs, MRIs and/or CTs
• Nuclear Medicine referral request form
• Oncology,Ìý Please make direct referral by calling (650) 497-8953.
• Occupational Therapy Services referral form
• Pain Management referral request form
• Perinatal Diagnostic Center (PDC) referral request form
• Pulmonary Clinic referral request form
• RadiologyÌýrequisition form
• Sleep Clinic referral request form
• Speech-Language Pathology Services referral form
• Urology, Please include pertinent labs and radiology reports
• Center for Healthy Weight referral request form, Please include growth chart

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