Direct Referral Form
The following patients are being referred for thermographic evaluation.
Patient Name(s)
*
Rows
Last
First
Date of Birth
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10
Comments
BTI Technician Name
*
First Name
Last Name
Ordering Provider
*
First Name
Last Name
NPI
*
Provider License Number
*
Ordering Provider Email
*
example@example.com
By checking this box and signing below:
*
I acknowledge that my license is currently active, has NOT expired, and has NO restrictions.
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 (if not applicable, indicate N/A)
*
Signature of Technician Uploading a Written Referral Signed by the Physician (if not applicable, indicate N/A)
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Written Referral File Upload
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All written referral forms must have physician signature and NPI and active license number.
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