Physician Referrals — Atlanta

Refer your patient to Premier Hematology.

Our team reviews all referrals within one business day. We coordinate directly with your office to ensure a seamless transition of care and will send a full report after the patient's visit.

✓Specialist response within 1 business day

✓Full report sent after patient visit

✓Direct fax line available

✓13 locations for patient convenience

Physician Referral Form — Atlanta

Complete all fields. Chart notes can be uploaded or faxed to 718-866-3037.

Referring Physician

Referring Doctor / Practice Name *

Office Phone *

Office Fax

Patient Information

Patient First Name *

Patient Last Name *

Date of Birth *

Patient Phone *

Patient Address

Patient Email

Patient Insurance *

Insurance ID # *

Referral Details

Reason for Referral *

Upload Chart Note (PDF/image)

Referral Priority *