Referring Providers & Patients

Referral Form

Submit a patient referral to Ironwood Urology. Our team will follow up within one business day to schedule the patient's appointment.

Submit a Referral

How It Works

Complete This Form

Fill in the patient's information, insurance details, and reason for referral.

We Confirm Receipt

Our team receives the referral and reviews the patient's information.

We Contact the Patient

We reach out directly to schedule an appointment within one business day.

Prefer to refer by phone?

Call our office directly and our staff will take the referral over the phone.

(480) 961-2323

Mon – Fri, 8:00 AM – 5:00 PM

Note: This web form provides a convenient way to submit referral information. It is not a HIPAA-compliant secure messaging channel. For highly sensitive referrals, please call our office directly.

Patient Referral

Fields marked required are required.

Patient Information

First Name

Last Name

Date of Birth

Phone

Email (optional)

Insurance Information

Insurance Carrier

Member ID

Group Number

Referral Information

Referral Type

Referring Provider Self Referral

Reason for Referral

Additional Information (optional)

Privacy Notice: Information submitted through this form is received by Ironwood Urology staff and used solely to process this referral. This form is not a HIPAA-compliant secure messaging channel. Submission does not guarantee an appointment or establish a physician-patient relationship. For more information, see our Privacy Policy.

Questions about a referral?

Call our office and a staff member will be happy to assist.

Call (480) 961-2323 Contact Page