CONSULTATION REQUEST Patient’s Name: _______________________________________________________________ Date of Birth: ______________ SS #: _____________________ (we must have SS # to schedule appointment) Address: _______________________________________________________________ Home Ph #: __________________ Work Ph #: __________________ Cell #: _____________________ Medical Reason for Appointment: ________________________________________________________
Has patient had x-rays, MRI, ect.? Yes No (Patient must bring x-ray’s, MRI, ect. with them to the appointment) Was patient involved in an accident or injury?
Yes
No
MVA
W/Comp
If “Yes”, Date of Injury/Accident: _____________________________________
Other
*** Please advise patient that any copay/co-insurance is due at the time services are rendered *** Insurance Primary: ___________________________ Secondary: ___________________________ *** Patient must bring insurance card(s) and a picture I.D. at the time of the appointment *** Physician Requesting Consult: ________________________________________________________ Office Phone #: ___________________________ Office Fax #: ___________________________ I am requesting that Tallahassee Orthopedic Clinic or its affiliated satellite offices perform a consultation on the above referenced patient for the medical problem indicated. __________________________________________
Physician’s Signature
______________________________
Date
Appointment Information Date: ___________________________ Time: ___________________________ Location: __________________________________ Provider: __________________________________ *** Please note all information must be completed and signed before an appointment will be scheduled *** *** We will return this fax to you with an appointment date and time ASAP ***
