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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