Date
UrgentRoutine
REFERRING PROVIDER INFORMATION:
PATIENT INFORMATION (Please provide copy of patient demographics/face sheet):
Patient's DOB
Patient's Contact
Patient's GenderMaleFemale
Needs interpreter?YesNo
REASON FOR REFERRAL
Contact referring provider if requested physician is unavailable
Type of Service Requested:ConsultationFollow upSurgery2nd OpinionRadiology ServicesLab ServicesOther (please specify):
DOCUMENTATION REQUIRED {Please fax the following documents to 612-535-4647 or 1-800-933-0968): • Recent/relevant typed clinical notes/test results, I.e. history & physical, MRI/Ct/X-rays results • Proof of insurance • Authorization information (if required)
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