Online Referral Form for Providers

← Why choose us, and other ways to refer

Colonoscopy only, for a patient without GI symptoms? No referral is needed. Patients who qualify for direct access can schedule a colonoscopy without an office visit: give them our 5-minute questionnaire. Who qualifies.

Online Referral Form

For providers only. Use this form to securely submit a referral for your patients. Fields marked * are required. Prefer to fax? Open our referral form and fax it to 626-898-4561.

Do not use this form for urgent referrals or emergencies. For urgent referrals, call 626.898.4560.

Provider’s information

Enter the clinic or practice, the provider’s name, or both. The provider’s name is optional if you enter a clinic or practice.

Clinic or medical group name

Start typing the clinic or medical group name to search the public NPI Registry. Matches nearest to our office (Temple City, 91780) are listed first, and picking one fills in the clinic’s NPI, address, phone, and fax.

First name Middle name Last name

Title Provider’s NPI # (optional) Provider’s specialty

Start typing the provider’s name to search the public NPI Registry for physicians, nurse practitioners, and physician assistants, nearest first. Picking one fills in the name, NPI, specialty, address, phone, and fax. You can edit anything afterward.

Clinic or provider’s address

Street address

Street address line 2 City State ZIP code

Provider’s phone Provider’s fax Provider’s or practice’s email (optional) Confirm email

Patient’s information

First name Middle name Last name Date of birth

Patient’s gender MaleFemale

Patient’s address

Street address

Street address line 2 City State ZIP code

Patient’s phone Patient’s email Confirm patient’s email

Appointment information Reason for referral

Upload medical records

Optional. Up to 10 files, 15 MB total (PDF, images, Word, text). Records may also be faxed to (626) 898-4561.

Submitted securely to our office. Please do not send referrals for emergencies through this form.

Refer a Patient

Online Referral Form

Thank you! We received your referral.