Submit a Referral to Rochester Gastroenterology Associates
For referring offices only. Send patient details securely and RGA will review and contact your office. Submitting here does not guarantee an appointment.
Call RGA
The existing phone and fax referral workflow remains available and uncharged.
Referral Details
Referring practice
Practice name
*
Your name
*
First Name
Last Name
Callback phone
*
Format: (000) 000-0000.
Email (optional)
Patient
Patient name
*
First Name
Last Name
Patient address
*
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Legal sex
*
Male
Female
Patient phone
*
Format: (000) 000-0000.
Patient email
example@example.com
Request
Document upload
Upload Files
Drag and drop files here
Choose a file
Insurance information, records, etc.
Cancel
of
Office location
*
Please Select
Canal Landing
Hagen
Requested service
*
Please Select
Consultation
Colonoscopy
Endoscopy
Flexible Sigmoidoscopy
Capsule Endoscopy
Other
Indication for referral
*
Urgency
Routine
Soon
Urgent (not emergency)
Notes
Submit Referral
Should be Empty: