Home                                                         Referral Request

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If you have a problem for which you would like to be referred to a specialist, please fill out this form. Please check your insurance policy first as certain specialties, such as Ob/Gyn or optometry, may not need a referral. But if your insurance carrier requires a referral, contact us first, since we are not allowed to give referrals after the fact.

Also remember, it is frequently to your benefit to visit your primary care physician first, since many problems may not require a specialist visit, but are easily taken care of in our office.

Your first and last name:

Your Brattleboro Primary Care medical record number, if you know it:

Your date of birth:

Your telephone number with area code:

Your email address:

Which specialty would you like to be referred to?

Who would you like to see?

Please use the space to describe your medical problem. We will try
to get back to you within two to three business days, but if you haven't heard
from us by then, please call the office directly.
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