Return to Referral Page
 
Charter Internal Medicine, LLC .
Request for Referral
 
Please complete ALL information!
If you do not know the information, put UNKNOWN in the box.
(this includes phone numbers)
 
 
Patient's Name:
Email address:
 
Patient's Date of Birth (EX: 23 February 1943):

      

Enter Patient's HOME Phone Number (area code first):

      

Enter Patient's WORK Phone Number (area code first):

      

Name of Patient's Insurance Carrier:

      

Insurance Carrier Identification Number:

      

Name of DOCTOR you need the REFERRAL for?

      

What is this Doctor's SPECIALITY?

      

Enter Specialist's PHONE Number (area code first):

      

Enter Specialist's FAX Number (area code first):

      

Date for which you want the Referral? (EX: 21 April 2003):

      

Who is your primary care physician?
  Harry A. Oken, MD
  Jerry E. Seals, MD
  Jonathan S. Fish, MD
  Kevin E. Carlson, MD
  Elizabeth S. Bower, MD
  New Doctor, MD

Is this a Follow-up or a New consultation?       

Diagnosis / Symptoms / Description of Problem / Comments

      

Click Submit Button ONCE
then wait for a copy of your Referral Request to appear.