Patient Referral Form
If you have an emergency and would like for your patient to be seen as soon as possible, please call us directly at (719) 473-9595 ext. 0
Date
*
-
Month
-
Day
Year
Date
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Patient's Home Phone Number
*
Please enter a valid phone number.
Patient's Work Phone Number
Please enter a valid phone number.
Patient's Cell Phone Number
Please enter a valid phone number.
Reason for Consultation/Diagnosis:
*
How long have symptoms been occurring?
*
Schedule Appointment:
*
Today
Within 2-3 days
Within 1 week
Next Available
Referring Physician Name
First Name
Last Name
Referring Physician Location
Physician Phone Number
Please enter a valid phone number.
Physician Fax Number
Please enter a valid phone number.
Physician Email Address
example@example.com
Tri-Care Prime Patient? Authorization MUST be requested by Referring Doctor:
Completed
Not Completed
Preferred Location
Colorado Springs Central Office
Colorado Springs North Office
Pueblo Office
Patient Demographics
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Patient Forms
Please upload patient forms below, or if you prefer to fax this information please send to:(719)227-0669
Patient Insurance
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Exam Notes
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OCT/FA Images
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Submit
Should be Empty: