For provider offices

Refer a patient for injection services

Send a secure injection-service patient referral for review. Our team will verify the request and coordinate next steps with the patient and your office.

Patient information

Only the essentials needed for our team to follow up.

First name

Last name

Date of birth

MM/DD/YYYY

Gender

Used to establish the patient profile.

Preferred contact

Patient phone

Injection information

Medication and timing help us prepare the referral.

Medication or injection name

Choose from the catalog, select Unknown, or enter a medication name manually.

Last known injection date (if known)

MM/DD/YYYY

Next injection due date (if known)

MM/DD/YYYY

Referring practice

Start with the referring clinician's NPI, then review and confirm the practice details.

Referring clinician NPI

Required. We use the public NPPES registry to prepare details for your review.

Referring clinician or organization

Enter the name if the registry lookup is unavailable.

Practice name

Search for the practice, or correct the registry details manually.

Practice address

Enter the practice address if known.

Office contact name

Recommended so our team knows who to contact.

Office contact

Provide an office phone or email. You may include both; fax is optional.

Office phone

Office email

Office fax (optional)

For documents or follow-up.

Supporting documents (optional)

Attach referral orders or recent notes. PDF, CSV, Excel, Word, JPG, PNG, and TIFF files are accepted; up to 5 files, 4 MB each.

Choose documents

For your privacy, uploads are sent only to restricted referral storage for staff review. Do not attach insurance card numbers, government IDs, payment information, or unrelated records.

AcknowledgementsI have read the Notice of Privacy Practices and understand this referral will be reviewed before services are arranged.I am authorized to submit this referral and share the information above for Rex Pharmacy to contact the patient and our office about this request.