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Referral Request

Thank you for choosing Marshfield Clinic. Please complete the form below and include 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



Address: 123 Main St. City, State Zip

File Attachments

Please attach patient demographics, insurance and pertinent medical records 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 715-858-9191 for assistance.