Orthopaedics Hand Referral

If the patient is under the age of 17, please refer to Children's of Alabama https://www.childrensal.org/services/orthopedics

Patient Name(Required)

First Last

Date of Birth(Required)

Date of Referral(Required)

Date of Injury(Required)

Referring physician/provider:(Required)

First Last

Contact Phone # for Referring Physician(Required)

Diagnosis (Please be specific as to which part of the hand or wrist is involved)(Required)

Reason for referral (i.e. Second opinion, acute treatment, higher level of care, etc.):(Required)

Imaging completed (Xray, MRI, CT, EMG/NCV, etc.):(Required)

Previous Surgeries(Required)

Yes

If yes, please include procedures and dates(Required)

*Must have all Diagnostic Imaging Reports and Operative Reports faxed to 205-930-8923 for review. All hand surgery consult referrals are subject to review for appropriate patient care and referral flow. You may receive a call to discuss the referral or to redirect you to a more appropriate service.