For Referring Providers

Refer a Patient Online

We maintain same-day capacity for urgent add-on consults. Our office will call your patient to schedule and keep you updated on findings and plans. Prefer fax? Download the referral form on the referrers page and fax to (408) 871-2377.

Received — thank you. Our office will call you, usually within 1–2 business days. If this is urgent, call (408) 376-3626 now.

Something went wrong sending the form. Please call the office at (408) 376-3626 or fax (408) 871-2377 — we don't want to miss you.

Website

Referring provider

Provider name *

Practice name (optional)

Office phone *

Office fax

Office email

Provider's Direct Cell

If you would like direct patient updates from Dr. Gupta.

Patient

Patient name *

Patient phone *

Second patient phone number (optional)

Insurance

Other reason / details

Is this referral urgent? *

Yes — urgent No

Upload additional clinical files (optional)

Optional — additional demographic, insurance, or clinical notes will help expedite this referral request. Up to 3 files, 4 MB total; attachments are sent with the referral.

Submitted information is securely transmitted and protected. For emergencies call 911.