Requesting a Physician Referral

Thank you for allowing us to help you find a physician for your health care needs. Our staff of nurses and referral specialists is available from 8 a.m. to 7 p.m., Monday through Friday to assist you in finding a physician who best meets your needs. All of the physicians participating in this service have admitting privileges at Sacred Heart Hospital.

Please call (850) 416-1600 or toll-free 1-877-416-1600 for this free service, or complete the form below and submit it to us by pressing the "Submit Your Request" button at the end of the page. Be sure to provide all the information so that we may contact you easily and find the appropriate physician.

If you do want a call back, please indicate your phone number and the best time for us to call. We also can send information to you in the mail or by email.

Notice:

• If you are under 13, you may not send any information to us without your parents' permission.
  
  
• Filling out the following form does not set up an appointment with a doctor. You will be contacted with information regarding a physician that best suits your needs. You will need to contact this doctor to set up an appointment if you wish to see them.

NOTICE: If you are experiencing a medical emergency, please dial 9-1-1 on your telephone. These online services are for residents in Northwest Florida and South Alabama and are not intended for emergency situations.

If you want to make an appointment with your doctor, please contact your doctor's office. The Sacred Heart Call Center is unable to make appointments for you.

Online Request Form:
1.	FIRST NAME	LAST NAME
2.	STREET ADDRESS	CITY
3.	STATE	ZIP
4.	EMAIL	DATE OF BIRTH
5.	PHONE NUMBER	BEST TIME TO CALL
6.	NAME OF HEALTH INSURANCE CARRIER
7.	Are you looking for a physician? (IF NOT, SKIP TO QUESTION #11)    YES     NO
8.	What kind of physician would you like to see?   Primary Care Ob/Gyn Pediatrician Specialist
9.	What is your reason for wanting to see a physician?
10.	Please indicate your preference for the location of the doctor's office:  Close to my home  Other  No preference on location
11.	If you want us to find a physician in a location other than your home area, please specify the community or neighborhood you desire:
12.	How would you like us to contact you to respond to your request?  By telephone (SEE QUESTION #14)  By email  By U.S. Mail
13.	When we call, may we speak to anyone in your household other than you?   YES     NO Name of individual with whom we may speak:
Important notes: The transmission of this message over the Internet is not protected and there is a small possibility that it could be intercepted by unauthorized persons. You may prefer to discuss the reason for your appointment over the phone by calling (850) 416-1600 or 1-877-416-1600. Once this information is in our possession, it will be shared only with those involved in your care. Call Sacred Heart aims to provide accurate health information in a manner consistent with the values of the Daughters of Charity National Health System. Information you receive is not a substitute for a visit with your physician. We encourage you to use this information to find the physician who best meets your needs.
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