Physician Referral Form

Please complete this online form on behalf of your patient to begin the scheduling process. UVVC will contact your patient directly to schedule an appointment. If you prefer, you can also contact us by phone:

Patient Center: 1-800-950-8340
Fax: 1-888-989-8340
Hours: Monday – Friday, 7:00 AM – 6:00 PM EST

What You’ll Need
Whether you’re submitting the form online or calling us directly, please have the following information ready:

• Referring physician or practice details 
• Patient’s full name, contact information, and date of birth 
• Reason for visit 
• Patient’s primary insurance information

Once you’ve gathered everything, refer a patient to United Vein & Vascular Centers. Not all patients require a confirmed diagnosis to be seen at United Vein & Vascular Centers, please provide as much information as possible.

Major insurance providers currently accepted. We are in network with Medicare and commercial products including Marketplace.