We are always grateful when other physicians trust us with a patient referral. To expedite your patient’s care, please include ALL of the following information when submitting your referral:
Patient Referral Information Sheet
- Legible copies of insurance cards (front & back)
- Patient demographics and contact information
- Most recent office note pertaining to the issue
- Current medication list and surgical history
Additional information is required if your referral pertains to any of the following:
SKIN LESIONS
- All pathology associated with the lesion(s)
PANNICULECTOMY
- Documentation of stable weight (most recent six months)
- Documentation of symptoms and attempted conservative treatment (patients must be 18 months post-bariatric surgery, if applicable)
BREAST REDUCTION
- Documentation of patient’s current BMI
- Documentation of symptoms and attempted conservative treatment (most recent mammogram, if over age 40)
BREAST RECONSTRUCTION
- All pathology related to diagnosis (including most recent mammogram)
- OP report of mastectomy/lumpectomy (if already performed)
We thank you for your consideration as a partner in your patient care team. If you have any questions, please contact our office directly at (740) 653-5064.
