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Fullerton Genetics Center
9 Vanderbilt Park Drive, Asheville, NC 28803
Phone: 828-213-0022 Fax: 828-213-0039
Referral Form
PATIENT INFORMATION
Date: _____________________________________
Patient Name: _______________________________________________________________ DOB: _________________ Male _____ Female _____
Parents/Guardians: _____________________________________________________________________________________________________________
Address: _________________________________________________________________________________________________________________________
City: ______________________________________________________________________ State: ______________________ Zip: ____________________
Home Phone: ____________________________ Work Phone: ____________________________ Cell Phone: ______________________________
Insurance: _____________________________________________________________________ Interpreter Needed: Yes________ No_________
REASON FOR REFERRAL: *Please send records with referral*

Genetic Evaluation for: ___________________________________________________________________________________

Genetic Counseling for:

Cancer Counseling for: ________________________________________________________

Prenatal Counseling - Gestational Age: ________

Other: ___________________________________________________________________________

Fetal Alcohol Spectrum Disorder Clinic

Personalized Medicine Clinic (Genetics of Drug Metabolism)

Other: _____________________________________________________________________________________________________
REFERRING PHYSICIAN INFORMATION
Referring physician: ________________________________________ Practice name: ________________________________________________
Contact Name: ____________________________________
Address: ________________________________________________________________________________________________________________________
City: ______________________________________________________________________ State: ______________________ Zip: ___________________
Phone #: ________________________________________________________ Fax #: _______________________________________________________
Primary Care Physician: __________________________________________________ Phone: _________________________________________
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