---
title: Primary Care to Hepatology Referral Form Template | Paperform
description: Comprehensive hepatology referral form for primary care providers including liver function tests, hepatitis screening, alcohol history, and cirrhosis risk assessment. SOC 2 compliant and easy to customize.
url: "https://paperform.co/templates/primary-care-to-hepatology-referral-form"
type: static
generatedAt: "2026-03-28T00:44:53.134Z"
---

[← Back to free form templates](/templates/)    ![Primary Care to Hepatology Referral Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/primary-care-to-hepatology-referral-form.png)
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### Streamline Hepatology Referrals with a Professional, Compliant Form

When your primary care practice identifies patients with abnormal liver function or potential hepatic conditions, a clear and comprehensive referral to a hepatology specialist is essential for optimal patient outcomes. This **Primary Care to Hepatology Referral Form** template from Paperform is purpose-built to capture all the clinical information hepatologists need to prioritize cases and prepare for consultations—without the administrative burden of incomplete referrals or follow-up phone calls.

#### Why hepatology referrals need more than a basic form

Liver disease presentations are complex and multifactorial. Hepatologists rely on detailed intake about liver function markers, viral serology, substance use history, metabolic factors, and imaging to determine urgency and differential diagnoses. Paper referral pads or generic online forms often miss critical data points, leading to delays, repeat testing, and frustrated patients and providers alike.

This template includes structured fields for ALT, AST, alkaline phosphatase, bilirubin, albumin, INR and platelet counts, plus dedicated sections for hepatitis B and C screening, alcohol consumption patterns using validated AUDIT-C questions, metabolic syndrome indicators, family history of liver disease, and known cirrhosis risk factors. The result is a referral that tells the full story—so hepatology teams can triage appropriately and patients get the right care, faster.

#### Built for primary care, internal medicine, and family practice workflows

Whether you're a solo GP, part of a multi-provider clinic, or managing referrals within a larger health system, this form template adapts to your workflow. Conditional logic ensures that follow-up questions appear only when relevant (for example, detailed alcohol use questions appear based on initial screening responses), keeping the form concise for both straightforward and complex cases.

You can embed the form on your practice website, share a direct link via your EMR, or send it securely to patients for pre-referral information gathering. Once submitted, responses can automatically route to your referral coordinator, populate a shared spreadsheet, or integrate with your practice management system via Paperform's native integrations or [Stepper](https://stepper.io) workflows—eliminating manual data entry and ensuring nothing falls through the cracks.

#### Secure, compliant, and ready for healthcare teams

Paperform is SOC 2 Type II compliant and offers data residency controls, giving your practice peace of mind when handling sensitive patient information. While not HIPAA-certified, Paperform's security features and flexible integrations make it a trusted choice for hundreds of healthcare practices managing non-PHI administrative workflows, referrals, and intake.

With this template, you'll reduce referral turnaround time, improve communication with specialist colleagues, and deliver a smoother experience for patients navigating the complexities of liver disease. Get started today and bring structure and clarity to every hepatology referral your practice sends.
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