PHYSICIAN REFERRAL FORM

Today's Date:Please enter date format as: mm/dd/yyyy) * required

Referring Physician: * required

Physician's Phone Number:(Please enter phone number format as: xxx-xxx-xxxx) * required

Physician's Fax Number:(Please enter fax number format as: xxx-xxx-xxxx)

Contact:

Reason for visit, please check one: Diabetes Thyroid Osteoporosis Pituitary Other* required

Last Name: * required

First Name: * required

M.I.:

Date of Birth:(Please enter date format as: mm/dd/yyyy) * required

Address:

City:

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Home Phone:(Please enter phone number format as: xxx-xxx-xxxx) * required

Work Phone:(Please enter phone number format as: xxx-xxx-xxxx)

Cell:(Please enter phone number format as: xxx-xxx-xxxx)

Do you have medical insurance?:(If yes, please enter the Insurance Provider's name and Policy/ID Number.) Yes No* required

Primary Insurance:

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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.