Referrals

To refer a patient to the Comprehensive Liver Center at Hartford Hospital, complete the on-line referral form below or call 860-972-4219.



Online Referral Form

Please note the following:

  • This form is to be completed by a referring physician.
  • A representative from the Comprehensive Liver Center will contact you within one business day.
 
(* = Required)
* Type of Consult:
Transplant Consult
Hepatobiliary Surgery 
Hepatology Consult
Hepatobiliary Tumor Consult
Reason for Referral:
Patient Information:
* Patient Name:
* Date of Birth:
 Address: Street 1
  Street 2
  City      
  State       Zip
  Country
Work Phone:
Home Phone:
Cell Phone:
Primary Insurance:
  Policy # Group #
Secondary Insurance:
  Policy # Group #
Referring Physician Information:
* Physician Name:
Practice Name:

 Address: Street 1
  Street 2
  City      
  State       Zip
  Country
* Practice Phone:
Practice Fax:
Practice Email Address:
Preferred Means of Communication: Phone   Fax   Email


Enter code shown above:
   

After submitting this form, please make sure to fax the following information to the Transplant Program office at 860-972-9972:
  • Insurance card(s) – front and back
  • Medical notes (H&P)
  • Diagnostic test results (i.e. CT, MRI, U/S of ABD, etc.)