[Pediatric Practice Name] Newborn · Infant · Child & Adolescent Care

[Month DD, YYYY]	[Chart 00000000]

[Referring Provider Name], [Credentials]

[Practice or Clinic Name]

[Street Address, Suite 000]

[City, ST 00000]

Re: [Patient Name] · DOB [MM/DD/YYYY] · MRN [00000000]

Dear Dr. [Last Name]:

Thank you for referring [Patient Name] to our service. I had the pleasure of evaluating them on [date] for [presenting concern]. This letter summarizes my findings, the assessment, and the plan of care we discussed together.

On examination the patient was in no acute distress, with vital signs within normal limits. Relevant findings included [findings]. We reviewed the outside imaging and laboratory studies you forwarded, which were consistent with [impression]. I have ordered [additional studies] and will forward results as they become available.

Our plan is to begin [treatment or intervention] and to reassess in [interval]. I have reviewed the risks, benefits, and alternatives with the patient, who voiced understanding and agreed to proceed. Please do not hesitate to contact me directly if the clinical picture changes in the interim.

Sincerely,

[Your Name], [Credentials]

[Title] · Board Certified [Specialty] · NPI [0000000000]