Referring Doctor’s Name:
[pic] NEW ADULT NEW ADULT PATIENT REFERRAL/CONSULTATION
Please fax completed referral form and attach copies of prior pertinent clinic notes, labs, radiological studies, operative reports to (919)966-0369. This information will help facilitate your patient’s appointment.
PATIENT INFORMATION UNC MR# (if known):
|Last name: |First name: |middle name: |
|PRIMARY PHONE: |ALTERNATE PHONE: |SEX: F M |BIRTH DATE: |
|RACE: |STREET ADDRESS: |
|CITY: |STATE: |ZIP: |
DIAGNOSIS
| |BILIARY COLIC | | |HERNIA |
| |COLON-DIVERTICULOSIS | | |INTESTINAL FISTULA |
| |COLON-DIVERTICULITIS | | |LIPOMA |
| |COLOSTOMY REVISION | | |PILONIDAL DISEASE |
| |GALLSTONES | | |SEBACEOUS CYST |
| |HEMORROIDS | | |SMALL BOWEL OBSTRUCTION |
Request for particular surgeon? Spanish Interpreter Needed? Yes No
|PRIMARY CARE provider INFORMATION |
|PHYSICIANS NAME: |
|PRACTICE NAME: |
|STREET ADDRESS: |CITY, STATE, ZIP |
|PHONE: |FAX: |EMAIL ADDRESS: |
|REFERRING Provider INFORMATION (IF different than above) |
|PHYSICIANS NAME: |
|PRACTICE NAME: |
|STREET ADDRESS: |CITY, STATE, ZIP |
|PHONE: |FAX: |EMAIL ADDRESS: |
|INSURANCE POLICY HOLDER INFORMATION |
|(PLEASE ALSO ENCLOSE COPY OF INSURANCE CARD) |
|POLICY HOLDER’S RELATIONSHIP TO PATIENT: |LAST NAME: |FIRST NAME: |
|SELF PARENT SPOUSE CHILD OTHER | | |
|SEX: F M |BIRTH DATE: |PRIMARY PHONE: |
|PRIMARY INSURANCE CARRIER: |POLICY #: |GROUP #: |EFFECTIVE DATE: |
|SECONDARY INSURANCE CARRIER: |POLICY #: |GROUP #: |EFFECTIVE DATE: |
-----------------------
UNC General Surgery
101 Manning Drive, Chapel Hill, NC 27514
Phone: (919) 966-4389 Fax (919) 966-0369
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