Request a Referral

To search our online physician directory, click here .
In case of an emergency or if you are having severe symptoms, call 911. Do not use this form.

Thank you for contacting Baptist Health Systems for a physician referral. All our physicians are members of Baptist's medical staff. There is no fee to you or to the physician for this service. Physicians are selected according to your specific wants and needs.

After you complete and submit this form, a Baptist representative will respond to you with physician information based on the answers you provide. You must provide either a telephone number or an e-mail address so that we may contact you with the information you have requested. To help us process your request promptly, please answer each question on the form.

If you need additional assistance, please call 601-948-6262 or 1-800-948-6262 Monday-Friday, 8:00 a.m. - 4:00 p.m.

First Name:


 
Middle:


Last Name:
 
 
Email:
 

Sex:
 
Address:
 
Apt#:

City:
 
State:
 
Zip:
 
Evening Phone Number:
 
Daytime Phone Number:
 
Date of Birth (MM/DD/YYYY):
 
Who is your health insurance provider?
 


Do you have Medicaid?
 
Do you have Medicare?

 
Select a specialty:
 

Select your preference of
physician's gender (optional):
Describe your symptoms or tell why you need a physician.