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Request a Physician Referral

ATTENTION:   If you are experiencing a medical emergency, please dial 9-1-1 on your telephone. This online referral services is not intended for emergency situations and is only intended for residents of Northwest Florida and South Alabama.

Thank you for allowing us to help you find a physician for your health care needs. Our staff of nurses and referral specialists is available from 8 a.m. to 5 p.m., Monday through Friday to assist you in finding a physician who best meets your needs. All of the physicians participating in this service have admitting privileges at Sacred Heart Hospital.

Please call (850) 416-4650 for this free service, or complete the form below and submit it to us by pressing the "Submit Your Request" button at the end of the page. Be sure to provide all the information so that we may contact you easily and find the appropriate physician.

If you do want a call back, please indicate your phone number and the best time for us to call. We also can send information to you in the mail or by email.


Service Notice:
  • *If you are under 13, you may not send any information to us without your parents' permission.
  • Filling out the following form does not set up or guarantee an appointment with a doctor.
  • You will need to contact this doctor to set up an appointment if you wish to see them.
  • You will be contacted with information regarding a physician that best suits your needs.
  • If you are trying to make an appointment with your existing Sacred Heart doctor, please contact your doctor's office directly. The Sacred Heart Call Center is unable to make appointments for you.

Please Provide Your Contact Details

 
SALUTATION
 
FIRST NAME

LAST NAME

STREET ADDRESS
 
CITY
 
STATE
 
ZIP CODE
 
EMAIL ADDRESS
 
PHONE NUMBER

BEST TIME TO CALL YOU BACK

NAME OF HEALTH INSURANCE CARRIER
 
 

Please Answer the Following Questions

1.) Are you looking for a physician?    YES     NO
1.) What kind of physician are you looking for?  
     
2.) What is the primary reason for wanting to see a physician?
     
3.) Please indicate your preference for the location of the doctor's office:
 Close to my home
 Other (Please specify in Question #4)
 No preference on location
     
4.) If you want us to find a physician in a location other than your home area, please specify the community or neighborhood you desire: 
     
5.) How would you like us to contact you to respond to your request?
 By telephone (Please answer Question #8)
 By email (Please provide an email address in the section above)
 By U.S. Mail
     
6.) When we call, may we speak to anyone in your household other than you?   YES     NO
Name of individual with whom we may speak: 
     
Important notes:  
  1. As with any online communications, the transmission of messages over the Internet may be intercepted by unauthorized persons. You may prefer to discuss the reason for your appointment over the phone by calling (850) 416-1600 or 1-877-416-1600. Once this information is in our possession, it will be shared only with those involved in your care.

  2. Call Sacred Heart aims to provide accurate health information in a manner consistent with the values of the Daughters of Charity National Health System. Information you receive is not a substitute for a visit with your physician. We encourage you to use this information to find the physician who best meets your needs.
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