Physician Referrals Form

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Consultation Referral Request Form

Consultation
Primary Physician Name
Address
Phone/fax
PRACID#
Consultation Action Requests
	Confirm diagnosis
	Advise as to diagnosis
	Suggest medication or treatment
Referral
	Retrun patient when concern is resolved
	Assume future care of patient within your are
Patient Information
Patient Name
Address
Phone
Date of birth
Tentative Diagnosis
Pertinent history, physical laboratory findings and special finacial considerations
Please select from the following
	Please see attached Consultation Letter
	See additional information attached
	Please call me when you have seen the patient
	I would like to receive periodic status reports
Consultant's Findings Dr Searles will provide a full consultation letter at the time of the consultation
	I would like to receive periodic status reports
	If patent does not show, contact us

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