Provider Referral

Reason for Referral

Routine ReferralUrgent Referral

Please describe reason for referral.

Please upload recent office note and referral.

Has patient had any special studies performed?

NoYesIncludes operative notes, swallow studies, lab work, etc.

Please upload any related documents

Has patient had any prior imaging?

NoYes

Please describe type of imaging, including approximate date and facility where imaging was performed.

Please upload imaging reports.

Note: Please have patient bring imaging disk to appointment with them. Recent imaging is required for all new patient appointments.

Yes - patient will bring diskNo - I will mail imaging diskIf mailing imaging disks, please mail to Attention: Laryngology Coordinator

Does patient have a trach?

NoYes

Brand

Size

Is it cuffed?

YesNo

Please upload any additional documents.