Refer a Patient

Refer a Patient

Thank you for referring your patient to Hoʻoilina Genomics Institute. This form provides preliminary referral information. Our team will review the referral and contact your office if additional information is needed.
Referring Provider
Provider Name

First NameLast Name
Clinic/Hospital/Practice Name
Specialty
Office Phone
Please enter a valid phone number.Format: (000) 000-0000.
Office Fax
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Patient Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Parent/Guardian (if pediatric)
Insurance
If known, please indicate the patientʻs primary insurance.
Reason for Referral
Primary Referral Indication (ICD code):
Specific clinical question:
Previous Genetics
Has genetic testing already been performed?
Has the patient seen a genetic counselor/geneticist before?
If yes, please briefly describe prior evaluation or testing (if known).
Please describe any pertinent information.
Uploads
Referral and/or Clinic note

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Genetic testing report

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Pertinent labs

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Imaging

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Pedigree

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Best way to reach you:
Referral urgency
Preferred appointment type
I understand this referral will be reviewed prior to scheduling and additional information may be requested if needed.
Should be Empty:

Referring Provider