Patient Referral Form

Referring a patient to Tri-State Orthopaedics? Send us the details below and our scheduling team will follow up directly with the patient.

Thanks for referring to Tri-State Orthopaedics. We have offices in Evansville and across the Tri-State. We offer Orthopaedic Urgent Care for accidents or injuries, call (812) 474-OUCH (6824). For non-urgent orthopaedic care, patients benefit from receiving multiple on-site services under one roof. Referrals are handled quickly useally in under 24 hours from forms submission. Once an appointment is confirmed will inform you staff for your records.

Referring Provider

Referring Provider Name *

Practice / Clinic Name *

Provider Phone *

Provider Fax (optional)

Provider Email *

Patient

Patient Name *

Patient Date of Birth *

Patient Phone (optional)

Referral Details

Preferred Location

Urgency *

Reason for Referral / Clinical Notes *

Attach Referral Notes / Imaging (optional)

Tap or click to upload notes, imaging, or referral paperwork

JPG, PNG, PDF · max 8 MB

Need to reach our scheduling team directly? Call us at (812) 477-1558.

Patient Referral Form

Referring Provider

Patient

Referral Details

Referral Submitted!

How Can We Help?

Patient Referral Form

Referring Provider

Patient

Referral Details

Referral Submitted!

How Can We Help?

Your Location

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Choose Your Provider

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Your Information

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Review & Confirm

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Start Urgent Care Check In

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