Referring Physician Checklist

Referring Physician Checklist

Your contact information:

• Name
• Address
• Phone number
• Fax number
• Email

Information about your patient:

• Name
• Birthdate
• Address
• Phone Number
• Social Security Number
• Insurance Information

Your patient's medical history and records:

• Medical History
• Surgeries/Procedures
• Devices: type/settings

Description of your patient's current medications:

• Type(s)
• Dosages
• Allergies

Diagnostic test reports plus actual films or tracings:

• Current Chest x-ray: films plus report
• Current Chest CT scan
• Complete Pulmonary Function Testing
• Other as available