For office use only: Received by __________ Date __________ Physician ____________________ Appointment Date & Time ____________________ New patient appointment letter sent _______________ Nurse’s notes __________________________________
Greenville Health System / Carolina Dermatology of Greenville 920 Woodruff Road, Greenville, SC 29607
Phone: 864-233-6338 Fax: 864-235-1982
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NEW PATIENT REFERRAL FORM Patient Information:
Date: __________________________
First, Middle Initial and Last Name _____________________________________________________________ Male
Female
Date of Birth: ________________________________ Last 4 digits of SSN: __ __ __ __
Address: __________________________________________________________________________________ Home Phone: _______________ Daytime Phone: _______________ Email: ___________________________ Race: ________________________Language: _________________ Ethnicity: __________________________ Needs Interpreter: Yes
o
Language Requested: ___________________________________________
If Minor, Parent or Guardian Name:_____________________________________________________________ Primary Insurance: ________________________________________ ID No: ___________________________ Secondary Insurance: ______________________________________ ID No: ___________________________ Please send copy of patient’s insurance card(s). Reason for Consult: ___________________________________________ Dx:___________________________ Has patient been previously evaluated for these concerns? If so, list treatments tried and failed: __________________________________________________________________________________________ Referring Provider: _________________________________________ NPI: ___________________________ Name of Practice: ___________________________________________________________________________ Address: __________________________________________________________________________________ Phone: ___________________________ Fax: ___________________________ Contact Person: _________________________ Extension: _________________________
--------------------------------------------------------------------------------------------------------------------------Please Fax this Referral Form, Medical Records including Pathology Reports, and a Copy of Insurance Card(s) to: (864) 235-1982 Thank You for Your Referral ---------------------------------------------------------------------------------------------------------------------------
Rev 7/19/18jr
