NEW PATIENT REFERRAL INFORMATION FORM



Contact:
Referring Physician: * required
Referring Physician Phone:(Please enter phone number format as: xxx-xxx-xxxx) * required
Referring Physician Fax:(Please enter fax number format as: xxx-xxx-xxxx)
Patient's Medical Records Included:
Reason for Referral:
Other Reason for Referral:
Patient's Last Name: * required
Patient's First Name: * required
Patient's Middle Initial:
Date of Birth:(Please enter date format as: mm/dd/yyyy) * required
Gender:
Address:
City:
State:
Zip Code:
Home Phone:(Please enter phone number format as: xxx-xxx-xxxx) * required
Work Phone:(Please enter phone number format as: xxx-xxx-xxxx)
Primary Insurance:
Primary Insurance Identification Number:
Primary Insurance Group Number:(optional)
Primary Insurance Contact Number:
Primary Authorization Number:
Primary Insurance Expiration Date:
Do you have medical insurance?:(If yes, please enter the Insurance Provider's name and Policy/ID Number.) * required
Secondary Insurance:
E-mail Address: * required
Secondary Insurance Identification Number:
Secondary Insurance Group Number:
Secondary Insurance Contact Number:
Secondary Authorization Number:
Secondary Insurance Expiration Date:
Primary Physician:
Physician's Phone Number:(Please enter phone number format as: xxx-xxx-xxxx)
Physician's Fax Number:(Please enter fax number format as: xxx-xxx-xxxx)
verification(Please enter the characters listed below)
* required
Today's Date:Please enter date format as: mm/dd/yyyy) * required

 

Office hours & Contact info.

Mon. - Fri., 8:00AM to 5:00PM
1705 S. Adams Street
Tallahassee, FL 32301
Office No.: (850) 224-7154
Email: patient@thyroidcenter.com


Patient Portal


AFTER HOURS CONTACT INFORMATION

You may contact our office number 24 hours a day. After hours, please call the main number and wait for instructions for non-emergency calls. If you have a life threatening medical emergency, call 911.

For medical questions and problems that cannot wait until the next business day, please listen to the message in its entirety for call back instructions. Weekend calls are forwarded to the on call physician.

Please Call Us

If your diabetes control has deteriorated suddenly such that frequent high or low blood sugar is a problem.

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