Refer your Patients

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Entrust our surgical sherpas to care for your patients

We served as a trusted extension of your team

Our Surgical Sherpas stand ready to receive your referral and we contact your patient immediately. Please fax medical records and any diagnostic imaging done for our review. We will keep you closely informed of your patient's progress and make sure you receive surgeon's notes and operative reports for your records. Please do not hesitate to call of text us at 214-642-6415 for any questions or needs that come up that we can solve for you immediately. Thank you for the opportunity to serve!

You may also fill out our Referral Form and fax it to the number in the form:

Cirugia Care - Consultation Referral Form
File Size:	692 kb
File Type:	pdf

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Referral form

Your Information (as Physician or Referral Coordinator):

* Indicates required field

Your Name *

First

Last

Your Email *

Your Phone Number *

Your Fax Number *

Name of your Physician *

Comment *

Your Patient Information:

Patient Name *

First

Last

Patient Phone Number *

Date of Birth *

Parent Name (if younger than 18) *

Patient Email *

Patient Employer (if available) *

Reason for Referral: (Surgery and/or Study)

Surgery Consult Requested (Choose one or more) *

General Surgery Bariatric Surgery Breast Surgery Foot & Ankle Surgery Gastroenterology Gynecology Hand Surgery Orthopedic Surgery Otolaryngology Pain Management Plastic Surgery Spine (Minimally Invasive) Urology Other (add below)

Study Requested (Choose one or more): *

Colonoscopy Upper Endoscopy Colonoscopy & EGD

Type: *

Diagnostic With Biopsy

REASON FOR STUDY/CONSULT: Please include ICD-10 Diagnosis Code if available. *

ADDITIONAL INFORMATION FOR STUDY/CONSULT: Please include Body Part, CPT Code if available. *

Submit

Cirugía Care y sus Guias Sherpas de cirugia te ofrecen un acompañamiento personalizado eliminando los miedos, obstaculos y los precios inflados del camino quirúrgico para que puedas concentrarte en tu curación. Tienes acceso a nuestros cirujanos, hospitales, servicios de diagnóstico y programas educativos.

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