Direct Referral Form
The following patients are being referred for thermographic evaluation.
Patient Name(s)
*
Last
First
Date of Birth
1
2
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4
5
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10
BTI Technician Name
*
First Name
Last Name
Comments
Ordering Provider
*
First Name
Last Name
NPI
*
Ordering Provider Email
*
example@example.com
*
By checking this box and signing below, I acknowledge and agree that I am the client’s physician and that I am solely responsible for reviewing, interpreting, and discussing the thermographic findings, including any clinical significance, recommendations, and follow-up, all within my authorized professional scope of practice.
Signature of Physician or Technician Uploading a Written Referral Signed by the Physician
*
Date
*
-
Month
-
Day
Year
Date
File Upload
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Written referrals upload here only. All referral forms must have physician signature and NPI number.
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