GASTROINTESTINAL CARE CONSULTANTS, P.A., (GICC,P.A.) - GASTROENTEROLOGY, HEPATOLOGY, GENERAL & ADVANCED ENDOSCOPY
PHYSICIANS REFERRAL FORM
 
 Please complete entire form and attach copies of prior pertinent clinic notes, endoscopy reports, path reports, labs, imaging results and discharge summaries. We cannot schedule an appointment until this information is received.       
 
PATIENT INFORMATION                 WHMC MR# (if known):
 
LAST: ______________________     FIRST:  __________________________
MIDDLE:__________________________
SEX: F____    M  ______                    BIRTH DATE:  __________________    
PRIMARY PHONE: ____________ WORK PHONE:____________________ PRIMARY INSURANCE CARRIER: ________________________________  
POLICY #: ___________      GROUP #: _____________    
 EFFECTIVE DATE: ____________
POLICY HOLDER’S RELATIONSHIP TO PATIENT:  SELF  PARENT  SPOUSE  CHILD  OTHER
 
SECONDARY INSURANCE CARRIER:  INSURANCE:_______________________________________________       
POLICY #:   ____________   GROUP #:  ___________    
EFFECTIVE DATE:    ____________   
 (PLEASE ALSO ENCLOSE COPY OF INSURANCE CARD)
POLICY HOLDER’S RELATIONSHIP TO PATIENT:  SELF  PARENT  SPOUSE  CHILD  OTHER
REFERRAL DATE:_______________________________________________
AUTHORIZATION FIELDS  _______________________________________
 
CHECK SYMPTOM(S)/DIAGNOS(ES)                                                                     
 
  • Acute Pancreatitis
  • Bile duct stones
  • Chronic Pancreatitis
  • Gallstones 
  • Pancreatic Cancer
  • Pancreatic Disease
  • Pancreatic Insufficiency
  • Pancreatiobiliary Achalasia
  • Atypical Chest Pain 
  • Barrett’s Dyspepsia
  • Dysphagia
  • Esophageal Disease
  • Esophageal Motility
  • H.pylori
  • Reflux
  • Swallowing Disorder
  • Crohn’s Disease
  • IBD
  • Perineal Crohn’s Disease
  • Pouchitis
  • Ulcerative Colitis
  • Chronic Abdominal Pain 
  • Chronic Constipation
  • Chronic Diarrhea
  • Fecal Incontinence
  • Functional Disorders
  • IBS
  • ConstipationDiarrhea
  • GI Bleed
  • GI Malignancies 
  • Hematemesis
  • Motility
  • ProblemOther:    _____________
 
 
  • All new patients are seen for an initial consultation.
SPECIFIC QUESTION(S) TO BE ADDRESSED:
           
Spanish Interpreter Needed?  Yes    No
 
 
REFERRING PHYSICIAN INFORMATION
PHYSICIANS NAME: ____________________________  
PRACTICE NAME: _____________________________________________
STREET ADDRESS:_____________________________________________  
______________________________________________________________________________
CITY _______________________________  STATE ___________________ 
ZIP  __________________     
PHONE: ____________________________     FAX:  _____________________
EMAIL ADDRESS: _____________________________________________