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Physician Referral

UNC OB/GYN Physician Referral Form

Patient Information

Patient First Name (Required)

Patient Last Name (Required)

Patient DOB (Required)

Please enter MO/DA/YR

Medical Record Number

Please enter UNC MR number if patient has been seen here before

Patient Preferred Phone Number (Required)

Alternate Phone Number

Interpreter

Is an interpreter needed for the patient's visit

Yes

Language other than Spanish?

Please provide information about language spoke by patient so that we can have appropriate interpreters during the visit.

Insurance Information

Insurance Authorization Required

Yes

Insurance Authorization Information

If authorization is required by patient's insurance company, please provide authorization number, number of visits allowed and effective date.

Referring Clinician

Clinician Name (Required)

Phone Number (Required)

Beeper Number

Specific Question

What is the specific question(s) you want addressed in this consultation?

Disclaimer and Notice of Privacy Practices and regarding the use of e-mail (Required) (Required)

Yes, I have read and understand the Disclaimer and Notice of Privacy Practices and regarding the use of e-mail. (Required)

Yes

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