Clinic Forms

Patient Referral Forms

  • UTHA Referral Form - Print and complete this form and fax to: 512-495-5680
  • Comprehensive Memory Center - Due to a current waitlist of 4-6 months, at this time only internal referrals from UT Health Austin providers are being accepted.
  • Livestrong Cancer Institutes and Surgical Oncology - Print and complete UTHA Referral Form and fax to: 512-495-5709
  • Authorization To Release Records Form - to expedite the referral process

Medical Record Forms

Additional Patient Policies