Physician's Offices:
When referring a new patient to our office we will need a faxed copy of:

• Name of referring office, phone number and fax number
  

• the patient's D.O.B, address and phone number
  

• a copy of the patient's insurance card

• any office notes and/or test results pertaining to their appointment with us.

Once we have received all of this information, our office will contact the patient to set up an appointment. Please advise your patient  that there will be three appointments: a consult, procedure and follow-up. The doctor will send notes (if requested) once treatment is complete. Thank you.

Consult Request Form
File Size:	31 kb
File Type:	docx

Download File

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Phone: 434-296-6461   Fax: 434-296-7529