Submit a Patient Referral

Use this form to refer a patient to PHC or to initiate a co-management consultation. A member of the PHC team will follow up within one business day. If you'd prefer to speak directly with Dr. Wilcox before submitting a referral, call 832-281-5199.

Referral Information

Fields marked with * are required. Do not include patient last name — first name and clinical details are sufficient for initial intake.

Referring Clinician

Your Name *

Clinic / Practice Name *

Your Phone *

Your Email *

Patient Information

Patient First Name Only *

Patient Age *

Patient Sex *

Male Female

Reason for Referral / Brief Clinical Description *

Follow-Up Preference

Preferred Contact Method *

Call Me Email Me Either Is Fine

Additional Notes for Dr. Wilcox

This form transmits referral information to drwilcox@precisionhormoneconsulting.com. Do not include patient last name, date of birth, insurance information, or any other identifying details. This form does not establish a physician-patient relationship between PHC and the referred patient.

✓

Referral Received

Thank you. Dr. Wilcox will follow up with you within one business day using your preferred contact method. If you need to reach PHC sooner, call 832-281-5199.

— On HRT but still symptomatic

— Thyroid involvement — DTE or compounded T3/T4 needed

— Adrenal fatigue or HPA axis dysfunction

— PCOS or PMDD

— Chronic fatigue, fibromyalgia, or dysautonomia

— Functional medicine or gut health workup needed

— Advanced peptide therapy indicated

This referral form transmits information to Precision Hormone Consulting for the purpose of initiating a clinical referral. Do not include patient last name, date of birth, Social Security number, insurance information, or any other identifying details beyond first name. Submission of this form does not guarantee acceptance of a referral or establish a physician-patient relationship between PHC and the referred patient. PHC provides telemedicine services to patients in Texas and Arizona.

Submit a Patient Referral

Referral Information

Referral Received

Speak With Dr. Wilcox Directly

Who PHC Is Built For

After You Submit