Provider Referral Form - Center For Womens Surgery (Page 2 of 2) in pdf

Provider Referral Form - Center For Womens Surgery Page 2

Provider Referral Form to Amy Garcia, MD

Date:

___ Referring Provider Name:

Office Address:

Office Phone:

Fax:

Contact person:

Would the provider like to speak personally with Dr. Garcia prior to the patient being seen? (circle one)

YES

If yes, Dr. Garcia will call the provider.

Patient Name:

Date of Birth:

Phone #1:

Phone #2:

Email:

Insurance:

Primary language (circle) English

Spanish Other

I am referring this patient to Dr. Garcia for the following issue(s): Check all that apply

Cervical dysplasia

Heavy menstrual bleeding

Essure hysteroscopic sterilization

Menopausal bleeding

In-office hysteroscopy

Ovarian cyst/mass

Laparoscopic hysterectomy

Permanent contraception

Urinary Incontinence

Uterine fibroid(s)

Intrauterine device placement

Uterine polyp(s)

Other:________________________________________________

______

Additional description of patient and her gynecologic issues: (optional)

Referring Provider Signature: _________________________________________

Please submit this form and pertinent office notes, imaging, pathology and operative reports via

FAX 866-881-5131 or mail to 201 Cedar SE, Suite 505, Albuquerque, NM 87106.

We will contact your patient promptly to give instructions and appointment time.

Thank you for your referral. We strive to give your patient excellent care and to communicate with you

about all findings and recommendations.

201 Cedar SE, Suite 505, Albuquerque, NM 87106 (p) 505.554.3507 (f) 866.881.5131

Updated

5.12.14

Provider Referral Form - Center For Womens Surgery Page 2