FAX (850)878-8305 ... For referring Physicians, PLEASE complete the following information then fax back to 850-878-0552
Tallahassee Pulmonary Clinic, P.A. Pulmonary Medicine – Critical Care 1401 Centerville Road, Suite G-02 Tallahassee, FL 32308 (850)878-8714 (850)878-5138 FAX (850)878-8305 John S. Thabes - M.D. Carlos E. Campo - M.D. 2626 Care Drive, Suite 101 Tallahassee, FL 32308 (850) 877-1528 FAX (850) 671-3444
Clifton J. Bailey - M.D. J. Daniel Davis - M.D. David Y. Huang - M.D. F. Ray Dolly - M.D. Praful B. Patel - M.D.
NEW PATIENT INTAKE FORM For referring Physicians, PLEASE complete the following information then fax back to 850-878-0552 with the diagnosis appropriate records. Once received, we will call the patient with appointment. Before we are
able to schedule your patients, we must have all records pertaining to the referring diagnosis. (ie: notes, CXR/CT reports overnight Pulse Ox, PFT’s) THANK YOU.
Date of Appt: ______________________ Time: __________ Physician: ______________________ Patient information sheets sent on: ________________________________________________________ Canceled / Rescheduled by: ____________________________ OR ____________________________ M.D. Office (name & date) Patient & Date REASON FOR CANCELLATION: ________________________________________________________