Referring Physician Form - To Fill Out

The following is the referring physician form.  Please note the person having referred you to us.  As well, please add any physician or other provider you might want to learn what went on at your appointment.  If you would like a copy of the visit notes Dr Thomas will prepare, please note that on this form.  We also ask you to make note of any other person you would allow us to talk to about your care, even a family member. Otherwise, we would only talk with you.

Please print, fill out, scan, and email back to [email protected] or [email protected], or just bring to the appointment.  We will soon make this form fillable as well.  

If it is filled out in advance, your appointment should move along more quickly.