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TRIANGLE CHILDREN’S GASTROENTEROLOGY CENTER, PLLC 133 Keybridge Drive, Suite C, Morrisville, North Carolina 27560 Tel: (919) 677-8577 Fax: (919) 677-8580

REFERRAL FORM To make a referral, FAX this form to (919) 677 8580. Please include results of lab tests, radiology tests or other notes pertaining to the problem the patient is being referred for. Also include the growth charts (height and weight). For second opinions, if available, please include the reports of prior gastroenterology evaluation, endoscopy and biopsy reports. As soon as completed information is received we will contact the family to schedule appointment. PATIENT INFORMATION PATIENT NAME

DATE OF BIRTH

SEX

PARENT/GUARDIAN ADDRESS

DAYTIME PHONE

ALTERNATE PHONE INTERPRETER NEEDED? YES NO

SPECIAL NEEDS

INSURANCE INFORMATION INSURANCE

INSURANCE

ID#

REFERRING PRACTICE INFORMATION PRACTICE NAME

PHONE FAX

NOTES

REFERRING PHYSICIAN NAME

DATE


Referral Form – To make a referral, FAX this form to (919) 677 8580