West Clinical Research
4218-C Arendell Street, Morehead City, NC 28557
Clinician line (252) 515-0050 · info@westclinicalresearch.com
Patient referral form
Fax to: call (252) 515-0050 to confirm
Date sent
Pages (incl. this one)
Sent by
Call-back number
Please send only what you would include in a routine specialist referral. Do not include a date of birth — we do not need one, and we will not record it.
1. Referring clinician
Practice or clinic
Referring clinician (name and credentials)
NPI
Office phone
Office fax
Best contact at your office (name and direct line)
2. Patient
No date of birth. Age in years is enough for screening.
Patient name
Age (years)
Preferred phone
Alternate phone
Best time to reach the patient
City and ZIP
Preferred language
Email (optional)
Patient knows about this referral and agrees to be contacted
Patient prefers we contact the office first
3. Why you are referring
A study name, a condition, or simply what you are trying to solve.
Study or condition of interest
Primary diagnosis (and approximate date)
Relevant history, comorbidities, recent changes
Current medications (or check the attachment box below)
Relevant labs or imaging, with dates
Medication list attached
Recent labs attached
Relevant notes or imaging attached
4. Authorization to contact the patient
Placeholder wording — to be replaced with the reviewed text before this form is distributed
I confirm that I am the patient's treating clinician, that the patient is aware of this referral, and that the patient agrees to be contacted by West Clinical Research about participating in clinical research. I am sending only the information needed to assess whether the patient may be eligible for a study.
Clinician signature
Printed name
Date signed
If your practice requires the patient's own written authorization before releasing records, send it with this form or note below that it is on file with you.
Notes on authorization or records
What happens after you fax this
- A coordinator calls your office to confirm the referral came from you. This is a security step and happens before we contact the patient.
- We speak with the patient, explain the study, and screen them against the protocol.
- With the patient's written authorization, we can report the outcome back to your office. Referring does not transfer care.
Questions about a specific patient: call (252) 515-0050 — ask for the clinical research team. Mon-Fri 8:00 AM – 4:00 PM. Patients calling for themselves should use (252) 659-5222.