SMG Referral Request

SMG Referral Authorization Request

You may print this form and either FAX to your doctor at SMG at 650/725-7078 or bring the form by SMG between the hours 7:30am and 5:30pm.

Your Name: Preferred Phone No: Date:
Medical Record Number: Name of Primary Care Physician:
Is this a new or return referral?
Is this an urgent or routine visit?

Which clinic? Which physician (if known)?
Date of Appt (if known):
Reason for referral and other comments:

The SMG Service Standard for referrals is 24 hours to process your request and input the required referral into the on-line system. This will then allow you to make your appointment. Please call or email your doctor directly if you need any further information or help to process your request. Thank you for partnering with SMG for your care.