Refer a Patient to the Comprehensive Liver Center

* = required field

Comprehensive Liver Center Online Referral Form

Please note the following:

This form is to be completed by a referring physician. A representative from the Comprehensive Liver Center will contact you within one business day.

Patient Information


Referring Physician Information:


After submitting this form, please make sure to fax the following information to the Transplant Program office at 860-972-9972

– Insurance card(s) – front and back

– Medical notes (H&P)

– Diagnostic test results (i.e. CT, MRI, U/S of ABD, etc.)

Comprehensive Liver Center at Hartford Hospital