Please fill out the following form to refer a patient to Barrington Orthopedic Specialists. Additional Resources Referring Office Contact Information Referring Physician * Your Name * Phone Number * Email Address * Fax Number (optional) If you would like a confirmation of your patient's appointment, please provide your fax number. Patient Information Patient Name * Patient Date of Birth * Patient Phone Number * Patient Alternative Phone Number (optional) Patient Email Address * Patient Insurance Symptoms & Diagnosis * Was this injury/condition related to Workers' Compensation? Yes No Patient Has Completed Bone Scan CT Scan MRI EMG X-Rays Cast/Splint Applied Requested time to be seen: 1-2 days 3-5 days If requested to be seen immediately, please call our office at (847) 285-4200. CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.