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TUSCALOOSA UROLOGY CENTER

Dr. Raymond Poore, MD                Dr. Ingrum Bankston, MD        Dr. John Duffy, III, MD

Dr. Gregory Broughton, MD        Dr. Anne Scott, MD

1780 McFarland Blvd North

Tuscaloosa, Alabama  35406

Tel (205) 345-7351     Fax (205) 345-8476

Patient Referral Form

Please complete the information below as completely as possible to facilitate the care of your referred patients.  Thank you!  Please fax the completed form along with the pertinent medical records, progress notes, imaging results, laboratory studies, etc., to (205) 345-8476.  If you prefer, you can scan and email to doswalt@mdspn.com

PATIENT INFO

     

PATIENT NAME:         _________________________________________________________________        

DATE OF BIRTH:        _________________________________________________________________

PATIENT ADDRESS:        ____________________________________________________________

________________________________________________________________________________________________________________________

PATIENT PHONE:         ____________________________________________________________

REFERRING PHYSICIAN INFO

REFERRING PHYSICIAN:        ___________________________________________________________

REASON FOR REFERRAL:        ___________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________        

PREFERRED PHYSICIAN:        we will make every effort to schedule with the requested physician (circle)

FIRST AVAILABLE        POORE                BANKSTON              DUFFY            BROUGHTON                SCOTT

URGENCY:   Urgent (1-2 days) - please also call us directly (205-345-7351) to schedule urgent appointment

         1 week

         1 month

Patient Referral Form (v.7/2016)