The form and information provided below are for use by physicians, their office representatives and other care providers who wish to refer a patient for RADIOLOGY SERVICES at UTMB. Contact information collected via this form is used expressly to serve our referring physicians and their patients.
If you are a physician and wish to refer a patient for other services at UTMB, you may do so online.
Radiology Outpatient Diagnostic Order Form
Instructions: Please click to access our RADIOLOGY REFERRAL FORM
You may 1) print a blank copy of the form, fill in and fax; or 2) fill the form online, print and fax. Please remember to sign either
option and fax to the number of your specific clinic. A UTMB staff member will follow up with you promptly.
Non-UTMB Image Study Upload
To upload and share medical images taken elsewhere to UTMB, use the ImageShare tool.
For user tips and instruction on uploading non-UTMB images, access the ImageShare user guide