D.O.B.. Address: Home Phone: Work Phone: Cell: Referring Physician: Contact Name: Tel #:. Diagnosis: Insurance. Policy #
Southern Medical Group, P.A. Cardiology Division 1401 Centerville Road, Suite 800 Tallahassee, FL 32308 (850) 216-0120 Non-Interventional Cardiology J. Galt Allee, M.D.
Electrophysiology and Cardiac Pacing Marilyn M. Cox, M.D. Farhat S. Khairallah, M.D.
w/ Nuclear Medicine Frank E. Gredler, M.D. David W. Smith, M.D.
Interventional Cardiology Wayne Batchelor, M.D. John N. Katopodis, M.D. Earl McKenzie III, M.D. David L. Tedrick, M.D.
New Patient Intake Form For referring physicians, please complete the following information and fax back to (850) 201-4888, with diagnosis and appropriate records. Once received, we will call you with appointment date and time. Thank you. Patient’s Name: _____________________________________________ D.O.B. ________________________________ Address: __________________________________________________________________________________________ Home Phone: ______________________ Work Phone: ______________________ Cell: ________________________ Referring Physician: ___________________ Contact Name: ___________________ Tel #: ______________________ Diagnosis: _________________________________________________________________________________________ Insurance ___________________________ Policy # ______________________ Referral # ______________________ Patient’s Height: _____________________________________________ Weight: ______________________________ Lab Done (where): ________________________________ X-Ray Done (where) ______________________________ CT Done (where) ________________________________ EKG Done (attach) _________________________________ Reason for Referral ________________________________________________________________________________ Patient Needs To Be Seen: URGENT (today)
ASAP (this week)
Routine (this month)
(For our office only)
Date of Appt: ________________________________ Time: __________ Physician: ____________________________ PCP Called: ________________________________ Information Sheets Sent _________________________________ (date & initial)
(date & initial)
Cancelled By: _________________________________________ or _________________________________________ Physician’s Office (name & date)
Patient / Spouse / Parent (name & date)
Rescheduled: _____________________________________________________________________________ Reason for Cancellation: _____________________________________________________________________
