Physician Referral Online Form

Peninsula Podiatry respects your privacy:

We use secure site licensing and website encryption to keep your information safe and confidential. This form does not save or store any information to this website. Read our privacy disclaimer for more details.

Use the online form below to submit information regarding your patient. Once submitted, the referral goes to our office at which point we will contact the patient for appointment scheduling. We will contact you with any additional information required. A response usually takes within 1-3 business days. For additional questions or information, please contact us during regular business hours at (360) 641-7102 or send us an email at

In the event that your patient’s insurance company is not listed on our form below, please use the additional box provided under the list to specify who their insurance provider is. If you did not see your patient’s insurance listed, we may need to get a prior authorization. Please be aware this will somewhat delay the appointment process.

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