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PHYSICIANS REFERRAL FORM

 Please complete entire form and attach copies of prior pertinent clinic notes, endoscopy reports, path

reports, labs, imaging results and discharge summaries. We cannot schedule an appointment until

this information is received.       

PATIENT INFORMATION                    WHMC MR# (if known):

LAST:______________________     FIRST:__________________________

MIDDLE:__________________________

SEX: F____      M ______                              BIRTH DATE: __________________ 

PRIMARY PHONE: ____________ WORK PHONE:____________________

PRIMARY INSURANCE CARRIER: ________________________________

POLICY #: ___________      GROUP #: _____________    

 EFFECTIVE DATE: ____________

POLICY HOLDER’S RELATIONSHIP TO PATIENT: SELF PARENT

SPOUSE CHILD OTHER

SECONDARY INSURANCE CARRIER: INSURANCE:_______________________________________________       

POLICY #: ____________ GROUP #: ___________    

EFFECTIVE DATE: ____________   

(PLEASE ALSO ENCLOSE COPY OF INSURANCE CARD)

POLICY HOLDER’S RELATIONSHIP TO PATIENT: SELF PARENT

SPOUSE CHILD OTHER

REFERRAL DATE:_______________________________________________

AUTHORIZATION FIELDS _______________________________________

CHECK

SYMPTOM(S)/DIAGNOS(ES)                                                                     

  • Acute Pancreatitis
  • Bile duct stones
  • Chronic Pancreatitis
  • Gallstones
  • Pancreatic Cancer
  • Pancreatic Disease
  • Pancreatic Insufficiency
  • Pancreatiobiliary Achalasia
  • Atypical Chest Pain
  • Barrett’s Dyspepsia
  • Dysphagia
  • Esophageal Disease
  • Esophageal Motility
  • H.pylori
  • Reflux
  • Swallowing Disorder
  • Crohn’s Disease
  • IBD
  • Perineal Crohn’s Disease
  • Pouchitis
  • Ulcerative Colitis
  • Chronic Abdominal Pain
  • Chronic Constipation
  • Chronic Diarrhea
  • Fecal Incontinence
  • Functional Disorders
  • IBS
  • ConstipationDiarrhea
  • GI Bleed
  • GI Malignancies
  • Hematemesis
  • Motility
  • ProblemOther:    _____________

  • All new patients are seen for an initial consultation.​

SPECIFIC QUESTION(S) TO BE ADDRESSED:

Spanish Interpreter Needed? Yes No

REFERRING PHYSICIAN INFORMATION

PHYSICIANS NAME: ____________________________

PRACTICE NAME: _____________________________________________

STREET ADDRESS:_____________________________________________

______________________________________________________________________________

CITY _______________________________    STATE ___________________

ZIP __________________

PHONE: ____________________________   FAX: _____________________

EMAIL ADDRESS: _____________________________________________

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