Online Referral Portal

Adolescent Medicine

• Adolescent Medicine Referral Guidelines
  Abnormal uterine bleeding, contraception, transgender care, eating disorders, depression/anxiety, sexually transmitted infections
• Adolescent Medicine Referral Request Form
  Fax completed form to 855-212-6740
• Adolescent Medicine Practice Profile

Allergy & Immunology

• CHOC Specialists Allergy & Immunology Referral Guidelines
  Allergic Rhinoconjunctivitis, Anaphylaxis, Asthma, Atopic Dermatitis, Drug Allergy, Eosinophilic Esophagitis, Food Allergy, Immunodeficiency, Insect Hypersensitivity,  Sinusitis, Urticaria / Angioedema
• CHOC Specialists Allergy & Immunology Practice Profile
  Provides a one-sheet resource of commonly treated conditions, services offered, location and contact information for referrals. For more comprehensive information, please see the Referral Guidelines.

Cardiology

• CHOC Specialists Cardiology Referral Guidelines
  Heart Murmur, Chest Pain, Syncope, Palpitations, Arrhythmia, Abnormal ECG, Hyperlipidermia, Genetic Disorders, Hypertension, Attention Deficit Disorder
• CHOC Specialists Cardiology Referral Request Form
  Fax completed form to 855-246-2329

• CHOC Specialists Cardiology Practice Profile
  Provides a one-sheet resource of commonly treated conditions, services offered, location and contact information for referrals. For more comprehensive information, please see the Referral Guidelines.

Endocrinology

• CHOC Specialists Endocrinology Referral Guidelines
  Growth Disorders, Thyroid Disorders and Pubertal Disorders including, Congenital Hypothyroidism (Neonate), Congenital Hypotheyroidism (Child), Acquired Hypothyroidism, Autoimmune Thyroiditis/Hypothyroidism, Central Hypothyrodism, Acquired Hyperthyroidism, Auntoimmune Hyperthyroidism (Grave’s Disease), Neonatal Hyperthyroidism, Goiter, Thyroid Nodule, Diabetes Mellitus Type 1 & Type 2, Hyperglycemia, Impaired Glucose Tolerance, Impaired Fasting Glucose, Morbid Obesity, Acanthosis Nigricans, Short Stature, Failure to Thrive, Precocious Puberty/Premature Thelarche (Girls), Precocious Puberty (Boys), Premature Adrenarch (Girls), Premature Adrenarch (Boys), and Delayed Puberty.
• CHOC Specialists Endocrinology Referral Request Form
  General Endocrinology Clinic, Growth Clinic, Diabetes Clinic
• CHOC Specialists Endocrinology Practice Profile
  Provides a one-sheet resource of commonly treated conditions, services offered, location and contact information for referrals. For more comprehensive information, please see the Referral Guidelines.

Gastroenterology

• • CHOC Specialists Gastroenterology Referral Guidelines
    Chronic Abominal Pain, Celiac Disease, Crohn’s Disease, Diarrhea, Hematochezia, Food Allergy, Peptic Ulcer Disease, Gastro Esophageal Reflux (GER), Vomiting, Constipation, Failure to Thrive.
  • CHOC Specialists Gastroenterology Referral Request Form
    Abdominal Pain, Diarrhea, Weight Loss, GI Bleed, GERD, Jaundice, Constipation, Growth Failure, Vomiting

Hematology

• CHOC Specialists Hematology Referral Guidelines
  Anemia, Thrombocytopenia, Neutropenia, Coagulation Defect, Recurrent Infections
• CHOC Specialists Hematology Referral Request Form
  Anemia, Thrombocytopenia, Neutropenia, Bleeding Disorders, Thrombosis, Recurrent infections, Di George Syndrome, Hypogammaglobulinemia, Chronic Granulomatous Disease, Hemangioma, Vascular Malformations, Port Wine Stain but no Lymphangiomas
• CHOC Specialists Hematology Practice Profile
  Provides a one-sheet resource of commonly treated conditions, services offered, location and contact information for referrals.

Hospitalist

• CHOC Specialists Hospitalist Practice Profile
  Provides a one-sheet resource of commonly treated conditions, services offered, location and contact information for referrals.

Infectious Disease

• CHOC Specialists Infectious Disease Practice Profile
  Provides a one-sheet resource of commonly treated conditions, services offered, location and contact information for referrals.
• CHOC Specialists Infectious Disease Referral Guidelines
  Recurring Fevers, Recurrent Staphylococcal Infections, Latent Tuberculosis Infection
• CHOC Specialists Infectious Disease Referral Request Form

 Metabolic Disorders

• CHOC Specialists Metabolic Disorders Referral Guidelines
  Developmental Regression / Cognitive Impairment, Hypotonia, Stroke-like Episodes, Intermittent Ataxia, Altered Mental Status, Medically Refractory Seizures, Failure to Thrive / Cyclic Vomiting, Recurrent Hypoglycemia, Abnormal Laboratory / Imaging Findings, Family History of Inborn Errors of Metabolism / SIDS, Positive Newborn Screening for Metabolic Disorders, Urea Cycle Disorders, Organic Acidurias, Amino Acid Disorders, Vitamin and Cofactor Disorders, Carbohydrate Metabolism Disorders, Fatty Acid Oxidation Disorders, Mitochondrial Disorders, Neurotransmitter Disorders, Lysosomal Storage Diseases. Peroxisomal Disorders, Creatine disorders, Purines & Pyrimidines disorders, Congenital Disorders of Glycosylation (CDG)
• CHOC Specialists Metabolic Disorders Practice Profile
  Provides a one-sheet resource of commonly treated conditions, services offered, location and contact information for referrals.

Neonatology

• CHOC Specialists Neonatology Practice Profile
  Provides a one-sheet resource of commonly treated conditions, services offered, location and contact information for referrals.

Nephrology

• CHOC Specialists Nephrology Referral Guidelines
  Microhematuria, Gross Hematuria, Proteinuria, Acidosis, Cystic Kidneys, Hypertension
• CHOC Specialists Nephrology Referral Request Form
  Microhematuria, Gross Hematuria, Proteinuria, Acidosis, Cystic Kidneys, Hypertension
• CHOC Specialists Nephrology Practice Profile
  Provides a one-sheet resource of commonly treated conditions, services offered, location and contact information for referrals.

Neurology

• CHOC Specialists Neurology Referral Guidelines
  Recurrent Unprovoked Seizures (Epilepsy), Febrile Seizures, First Unprovoked Seizure, Developmental Delay, Tics, Tourette’s, Autism, Pervasive Developmental Disorder, Concussion, Headaches
• CHOC Specialists Neurology Referral Request Form
  Intractable Epilepsy, General Neurology, Neuromuscular Disorders
• CHOC Specialists Neurology Practice Profile
  Provides a one-sheet resource of commonly treated conditions, services offered, location and contact information for referrals. For more comprehensive information, please see the Referral Guidelines.

Neurosurgery

• CHOC Specialists Neurosurgery Practice Profile
  Provides a one-sheet resource of commonly treated conditions, services offered, location and contact information for referrals.

Ophthalmology

• CHOC Ophthalmology Referral Guidelines
  Visual Behavior/Acuity, Eyelids, Nasolacrimal System, Anterior Segment, Ocular Media Opacieties, Sensorimotor System, Prematurity, Systemic Disorders, Congenital Syndromes, Non-Accidental Injury, Headaches
• CHOC Specialists Ophthalmology Referral Request Form
  Childhood glaucoma (infantile, juvenile and traumatic), Double vision (diplopia), Droopy eyelids (ptosis), Eye inflammation (uveitis), Infantile and childhood cataracts, Nasolacrimal duct obstruction (blocked tear ducts), Refractive errors (need for glasses/contacts), Retinopathy of prematurity and its complications, Strabismus (crossing or drifting of the eyes). Tearing eyes, Traumatic eye injuries.
• CHOC Ophthalmology Practice Profile
  Provides a one-sheet resource of commonly treated conditions, services offered, location and contact information for referrals.

Orthopaedics

• CHOC Orthopaedics Referral Guidelines
  Flat Feet, Intoeing, Chronic Knee Pain, Acute Knee Pain, Scoliosis, X-ray Procedure
• CHOC Orthopaedics Practice Profile
  Provides a one-sheet resource of commonly treated conditions, services offered, location and contact information for referrals.

Otolaryngology

• CHOC Specialsts Otolaryngology Practice Profile
  Provides a one-sheet resource of commonly treated conditions, services offered, location and contact information for referrals.

Pediatric General and Thoracic Surgery

• CHOC Specialists Pediatric General and Thoracic Surgery Practice Profile
  Provides a one-sheet resource of commonly treated conditions, services offered, location and contact information for referrals.

Plastic Surgery

• CHOC Plastic Surgery Program Profile
  Provides a one-sheet resource of commonly treated conditions, services offered, location and contact information for referrals.

Pulmonology

• CHOC Specialists Pulmonology Referral Guidelines
  Infant Apnea, Child Apnea, Asthma, Brochopulmonary Dysplasia (BPD), Chronic Cough, Cystic Fibrosis, Recurrent Pheumonia, Respiratory Syncytial Virus (RSV)
• CHOC Specialists Pulmonology Practice Profile
  Provides a one-sheet resource of commonly treated conditions, services offered, location and contact information for referrals. For more comprehensive information, please see the Referral Guidelines.
• CHOC Specialists Pulmonology Referral Request Form
  Download a PDF of the CHOC Specialists Pulmonology Referral Request Form
• CHOC RSV Referral Request Form
  Download a PDF of the CHOC RSV Referral Request Form

Radiology

• CHOC Radiology Department Exam Requisition Form
  Download a PDF of the Radiology Department Exam Requisition Form

Rehabilitation Services

• CHOC Rehabilitation Services Referral Request Form
  Download a PDF of the Referral Request Form for Rehabilitation Services

Rheumatology

• CHOC Specialists Rheumatology Referral Guidelines
  Arthralgias, Joint Swelling, Joint Contracture, Limp Joint, Weakness, Back Pain, Malar Rash, Proteinuria, Hematuria, Unexplained Fevers, Weight Loss, Skin Tightening, Extremity Color Changes, Iritis, Chronic Pain, Positive (+) ANA
• CHOC Specialists Rheumatology Referral Request Form
  Pain, Joint Swelling, Limpness, Fever, Rash
• CHOC Specialists Rheumatology Practice Profile
  Provides a one-sheet resource of commonly treated conditions, services offered, location and contact information for referrals. For more comprehensive information, please see the Referral Guidelines.

Urology

• CHOC Urology Center Referral Guidelines
  Balanitis, Bladder Stones, Circumcision (elective), Cloacal Anomaly, Congenital Adrenal Hyperplasia, Congenital Cystic Kidney, Duplicated Collection System, Dysfunctional Voider, Dysuria, Dysuria (psychogenic), Fistula (urethrocutaneous), Frequency, Hematuria (gross), Hematuria (microscopic), Hernia (inguinal), Hidden Penis, Hydrocele, Hydronephrosis, Hydronephrosis (congenital), Hypospadias (male), Incontinence (urine – non specific), Kidney Stones, Labial Adhesions, Meatal Stenosis, Megaureter, Megaureter (congenital), Micro Penis, Multi Cystic Dysplastic Kidney, Neonatal Circumcision, Neurogenic Bladder, Nocturnal Enuresis, Paraphimosis, Penile Adhesions, Penile Curvature, Phimosis, Posterior Urethral Valves, Pyelonephritis, Solitary Kidney, Spina Bifida (occulta), Testicular Pain, Testicular Pain (psychogenic), Torsion, Undescended Testis, Urachal Remnant, Ureteral Stones, Ureterocele, Ureteropelvic Junction (UPJ) Obstruction, Urethral Stones, Urethral Stricture, Urinary Retention, Urinary Tract Infection, Varicocele, Vesicoureteral Reflux, Vesicoureteral Reflux (bilateral), Vesicoureteral Reflux (nephropathy), Vesicoureteral Reflux (unilateral)
• CHOC Urology Center Referral Request Form
  Download a PDF of the CHOC Urology Center Referral Request Form
• CHOC Urology Center Practice Profile
  Provides a one-sheet resource of commonly treated conditions, services offered, location and contact information for referrals. For more comprehensive information, please see the Referral Guidelines.