Physician Referral

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Physician Referral

Tarrant Nephrology Associates Referral & Callback Service is offered for physicians of patients diagnosed with kidney disease who are interested in treatment offered at Tarrant Nephrology centers.

To refer a patient or receive a callback from our office, please complete the requested information below. You may also fax a referral directly to our new patient intake team at 817-882-9822.

Phone - 817-877-5858 and Fax - 817-882-9822 (Attn : New patient scheduling)

Locations

TNA - ARLINGTON
203 W. RANDOL MILL RD
ARLINGTON, TX 76011

Referral Form

* Denotes Required Field

Location: *

Physician First Name: *

Physician Last Name: *

Physician Phone Number: *

Physician Fax Number: *

Office Contact Name: *

Office Contact Email: *

Patient First Name: *

Patient Last Name: *

Patient Phone Number: *

Patient DOB: *

Additional Patient Information

Patient Contact Info

Address:

City:

State:

Zip Code:

Email:

Diagnosis

Chronic Kidney Disease Stage 1

Chronic Kidney Disease Stage 2

Chronic Kidney Disease Stage 3

Chronic Kidney Disease Stage 4

Chronic Kidney Disease Stage 5

Anemia

Protinuria

Hypertension

ESRD

Renal Mass

Renal Cyst

Kidney Stones

Others

Patient Insurance Info

Carrier:

ID Number:

I am ready to refer the patient for an appointment.

Have your scheduling staff..

Call the patient directly with an appointment time.

Call my office contact with an appointment time.

Contact me with an appointment time

Further Instructions if Required: