For Providers

Submit a Patient Referral

Select the appropriate referral form below, complete it, and fax it to our South Dallas location. All forms are pre-filled with our pharmacy information for your convenience.

Select & Complete the Appropriate Referral Form

Click a form to open it as a PDF. Each form is pre-filled with Vital Care of South Dallas contact information. If you do not see the correct form, please call 945.212.3707.

IV Antibiotic Referral Form

PDF

Immunoglobulin Referral Form

PDF

Home Infusion Referral Form

PDF

Alpha-1 Therapy Referral Form

PDF

Gastroenterology Referral Form

PDF

Immune Deficiency Referral Form

PDF