Simply replace the unfilled areas such as "" and "[date]" with your information.
I would like to refer [patient] to you for a consultation. [Patient] is a [age] year old [male/female] experiencing [chief complaint].
My immediate diagnosis is [diagnosis] and I would like to recommend [recommended treatment plan]. However, before going forward, I would like to get a second option from you. This is a pretty serious treatment option, and I would like to make sure you concur before we embark in this direction.
I have enclosed the pertinent medical records regarding [Patient] , and have directed [Patient] to call your office for an appointment. Please let me know if you won't be able to fit [Patient] into your schedule, so that I can refer [him/her] to someone else.