Referring Physicians

NEW PATIENT REFERRAL FORM

    GJR - IS THIS PATIENT BEING REFERRED FOR BONE MARROW TRANSPLANT?

    IS THIS A FORMER PATIENT?

    WHICH OFFICE IS THE APPOINTMENT SCHEDULED

    RECORDS TO BE

    New Patient Packet Mailed to pt

    Instructions:

    1. Ask the referring secretary to fax the following reports if pertinent: PATHOLOGY, PROGRESS NOTES, X-RAY REPORTS (to include any CT scans), copies of primary and secondary health insurance cards, and LAB RESULTS TO 843-577-6523. Have them put to your attention. MUST HAVE DOB ON THE INSURED IF NOT THE PT.
    2. If this is an out-of-town referral, ask them to send the actual slides and x-ray films to our office (this includes CT scans).
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