Referral Forms


To request an appointment for your patient by fax, please print and return these forms:

Referring physicians - use this form to schedule a radiology appointment with our Phoenix Children's Medical Group Radiologists. 

Radiology referral form (PDF)

Main number: (602) 933-1213

Radiology scheduling: (602) 933-1215  Fax: (602) 933-1214

Interventional scheduling: (602) 933-4444  Fax: (602) 933-1587

Surgeons - use this form when scheduling patients for surgery in Phoenix Children's operating rooms.

Surgery referral form (PDF)

Surgery block scheduling form (PDF)

Surgery Scheduling: (602) 933-1530

Surgery Fax: (602) 933-1553

Not sure about authorizations?

Links to health insurance plans (PDF)

List of common procedures requiring authorization, listed by health insurance company (PDF)

Specialty Service Referral Form
Fill out this secure, electronic form and we'll take care of the rest. You'll be notified as soon as your patient's appointment is scheduled.

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