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Referral Request

Thank you for choosing Marshfield Clinic. Please fax or email this form as well as any patient demographics, insurance information, applicable clinical notes, pertinent labs or imaging.

Has the patient received treatment under another name?
Is the referral to the Pain Clinic or Behavioral Health?
If yes, it is necessary to indicate if the patient is to be seen for:
Is this a work-related injury or illness?

Provider Information

First Last Name

Specialty / Practice


123-456-7890

123-456-7890

Address: 123 Main St. City, State Zip

File Attachments

Add any additional files or records needed below

Patient Information

Primary Care Provider:

Referral Details


Referral Information:


Other Information:

  • Invalid fields found. Cannot submit.
  • Emergent referrals require provider-to-provider contact with the call specialist. Call us at 715-858-9171 for assistance.