MCINTOSH CLINIC, P.C.. 119 WEST HILL STREET. THOMASVILLE, GA 31792. (229) 225-1900 or (800) 782-8507. Rheumatology Dept.
MCINTOSH CLINIC, P.C.
119 WEST HILL STREET THOMASVILLE, GA 31792 (229) 225-1900 or (800) 782-8507 Rheumatology Dept. Fax # (229) 225-3485
RHEUMATOLOGY CONSULTATION REQUEST ACKNOWLEGEMENT ATTN: _____________________________________ FAX #: ______________________________ REQUESTING PHYSICIAN: _____________________________________ PATIENT: _____________________________________ DOB: ______________________________ We have received your request for a Rheumatology consultation for the above-named patient for recommendations / opinions regarding: ____________________________________________________________________________________ ____________________________________________________________________________________ diagnosis / condition / signs / symptoms Please list any previous Rheumatologists the patient has seen: _________________________________ ____________________________________________________________________________________ Date of last visit: _______________________________________________________________
PLEASE FAX THIS SIGNED / DATED ACKNOWLEDGEMENT along with pertinent records, insurance and demographic information for the requested appointment to: (229) 225-3485 Acknowledge by: __________________________________________
Requesting Physician or Authorized Personnel
______________________________
Date
Appointment Date: ____________________________ Time: _________________________________ Appointment is with:
Dr. James Hunt
Dr. Victor McMillan
CONFIDENTIALITY NOTICE IF THE INFORMATION IN THIS FACSIMILE IS MEDICAL IN NATURE THEN IT IS LEGALLY PREVILEGED AND CONFIDENTIAL INFORMATION INTENDED ONLY FOR THE USE OF THE INDIVIDUAL NAMED ABOVE. IF THE READER OF THIS MESSAGE IS NOT THE INTENDED RECIPIENT, YOU ARE HEREBY NOTIFIED THAT ANY USE, DISSEMINATION, DISTRIBUTION OR COPY OF THIS FACSIMILE IS STRICTLY PROHIBITED. IF YOU HAVE RECEIVED THIS FACSIMILE IN ERROR, PLEASE NOTIFY US BY CALLING THE SENDER AND RETURN THE ORIGINAL MESSAGE TO US AT THE ADDRESS SHOWN ABOVE VIA THE UNITED STATES POSTAL SERVICE.
