DAVID GOLDSBURY CENTER FOR CHILDREN AND FAMILIES
All fields on this form are mandatory in order to best serve you and your families.
However, you may use your own clinic referral form if it contains all of the information below.
Complete and fax to (210) 704-4237 and call Central Scheduling at (210) 704-4100 for an appointment.
Families may call for the appointment after the form has been received.
Fax all documents relevant to the chief concerns (labs/radiology, growth charts, chart notes, etc.)
Date of Request:
Patient Diagnosis or ICD-9:
Reason for Consultation / Referral :
Select one: *Consultation for opinion only. Please return the patient to my care with written recommendations.
Referral for ongoing care of a particular problem. Please return the patient to me for general care.
Referral for a specified procedure. Please return the patient to me for general care.
*Note: If consultation only, clearly indicate above what question(s) you want answered.
Check if I would like the specialist to call or page me with results at this number ________________________________
applicable: after the visit.
Specialty Audiology Dental Ophthalmology
requested: Behavioral Health Clinic (Psychiatry) Diabetes / Endocrine Orthopedics
Cardiology Ear, Nose and Throat Pulmonology
Center for Reconstructive Surgery Gastroenterology Renal: Children’s Kidney Center
*Developmental Peds: Center of Hope *Genetics / Metabolism Urology
Developmental Peds: High Risk Infant Clinic Other: _________________________________________________
* Indicates specialties that require additional information prior to scheduling. Contact Central Scheduling at (210) 704-4100.
Check one: Schedule with a preferred physician (specify name): ________________________________________________
Schedule next available appointment / no physician preference.
Referring Physician: TPI #: Fax:
Address: NPI # Phone:
City: State: Zip:
Primary Care Physician (if different from referring physician):
Family’s Preferred Language: English Spanish Other (indicate):
Patient Name: Birth Date: SSN:
Home phone: Cell: Work: Alternative:
City: State: Zip:
Primary Insurance: Phone:
Group #: Policy #:
Subscriber Name: Subscriber Birth Date:
Authorization: # of visits:
CONSULTATION / REFERRAL FORM
CHRISTUS Santa Rosa Children’s Hospital
Center for Children and Families
333 N Santa Rosa St.
San Antonio, Texas 78207
Phone (210) 704-2335
From the North (Airport Area) or Northeast (Austin): Take the I-35 South exit towards Laredo. Stay in the upper level. Take Exit
#155C/Commerce St./W. Houston St.. (The ramp continues onto N. Pecos-La Trinidad St.) At the end of the ramp, take an immediate left
onto Martin St. Turn right onto N. Santa Rosa St. You will see “Visitor Parking” to your right.
From the Northwest (Medical Center, El Paso, Kerrville): Take I-10 East going towards downtown. Take Exit #569C/Santa Rosa St.
(The ramp continues onto Laredo St.) Stay in the left lanes, which curve left under the highway ramp and then into Santa Rosa St. (Follow
the sign towards Santa Rosa St. at the end of the ramp.) After the light for Martin St., you will see “Visitor Parking” to your right.
From South (Corpus Christi, Pleasanton, Laredo), West (Del Rio, Uvalde), and East (Seguin, Houston): Take the exit for I-10 West / I-
35 North into downtown towards El Paso. Take Exit #155B/W. Durango Blvd. Turn left onto S. Santa Rosa. Go straight on S. Santa Rosa
for approximately 0.5 miles. Turn left onto Houston St. Turn right onto N. San Saba St. Turn right onto Martin St. Turn right onto N. Santa
Rosa St. (This will take you around the city block for Santa Rosa.) You will see “Visitor Parking” to your right.