Download Pediatric ENT and Cleft Clinic

Referral Form
Dr. Anil Gungor- Pediatric ENT and Cleft Clinic
Department of Otolaryngology Head & Neck Surgery
Phone: 318-675-6262
FAX : 318-675-6260
Email: [email protected]
_______________________________
Patient Name
_________________________
Date of Birth
_______________________________
Street Address
_____________________________
Social Security Number
_______________________________
City, State, Zip Code
_________________
Home Phone
_____
Sex
________________
Alternate Phone
Insurance Information:
Company
Policy Holder
Policy Number
Group #
Phone #
*Please obtain any referrals needed and verify that LSUHSC- Shreveport is a participating provider.
Referral Information:
Referring physician: _______________________________________________________
Full Address: _____________________________________________________________
Phone: ___________________________
Fax: ______________________________
Chief Complaint/ Diagnosis: ______________________________________________________
Diagnostic Workup Completed
Tissue Biopsy (Pathology)
Cytology
Exploratory Surgery (Panendoscopy)
CT Scan Neck w/contrast
MRI Neck
PET Scan
Other Radiology
Other Nuclear Medicine Studies
Lab
Cardio/Pulmonary/Neuro Surgical Risk
Assessment (if applicable0
YES
NO
Please Fax:
 Copy of Insurance Cards
 History & Physical
 Previous Treatment Records
 Operative Notes
 Radiology Reports (send images with patient)
 Pathology Report
 Lab Reports
 List of Medications