It is important you notify us of any visits to the emergency room/hospital/ER/specialists office which were not a direct result of a referral from our office.
In order to keep our records complete, please advise us if you have visited an emergency room or urgent care within the past 90 days and you did not have a follow-up visit in our office.
Please update us on any specialist/testing visit you may have had in the past 90 days in which you did not get a referral from us. This includes a mammogram, a bone density test, a colonoscopy or other testing.
Please check all that apply for any visit you have within the past 90 days to a health care facility
Please list the approximate dates of the visit, the reason for the visit, any new medications prescribed or changes to existing medications, any additional testing done, any referrals done as a result of the visit or other information you feel important to include in your chart.
Please let us know if you have visited a specialist in the past 90 days that was not the direct result of a referral from our office. Include the name and type of specialist, the reason for seeing the specialist, any changes to your current medications and other testing that was done or ordered.
Please check all that apply for any of the above testing that was not directly ordered by our office within the past year
Please tell us which test (s) the approximate date, location where test was done, results if applicable or any other information you feel would be important to include in your chart.
Use this space to update on any other changes to your medical condition, medications or other information that you would included in your medical record.