Healthcare Practice Patient Referral Form

Building a strong patient referral program is one of the most effective ways for healthcare practices to grow—but managing referrals manually can be messy, time-consuming, and put sensitive information at risk. This Healthcare Practice Patient Referral Form template gives medical offices, dental practices, physical therapy clinics, chiropractic offices, and other healthcare providers a professional, compliant way to collect referrals and reward patients who bring in new business.

Designed specifically for healthcare environments, this template captures everything you need: referring patient details, new patient contact information, condition or reason for referral, consent acknowledgments, and even reward selection—all in one clean, easy-to-complete form. Whether you're running a dental practice, primary care clinic, specialist office, or wellness center, this template helps you turn word-of-mouth into a structured, trackable system.

With Paperform's conditional logic and payment integrations, you can tailor the form to your practice's unique referral program—offer gift cards, discounts on future services, or entries into a monthly prize draw. Submissions can automatically flow into your CRM or practice management system via Stepper workflows (stepper.io), triggering appointment reminders, reward fulfillment, and follow-up sequences without manual data entry.

While this template is not HIPAA-compliant (Paperform is not a HIPAA-compliant solution), it includes privacy-conscious design elements and consent language to help you handle referral information responsibly. For practices that need full HIPAA compliance, consider using this form as a front-end lead capture tool that feeds into your compliant systems via secure integrations.

The result? A referral program that feels effortless for your patients, professional for your practice, and powerful for your growth. Stop losing referrals to lost sticky notes and overflowing inboxes—start turning your happiest patients into your best marketing channel with Paperform.