GENERAL REFERRAL SHEET

Director: Deborah Negusse, MD, MPH

Please correct the errors described below.

(Office Managers: Corinne and Cynthia)

Referring Doctor’s Office:

PATIENTS NAME:

PATIENTS INSURANCE:

PATIENTS PHONE #:

Reason for consult: select from here

SCREENING (New Guidelines: Colonoscopy age 45)

NAUSEA/VOMITING

ABDOMINAL PAIN

FATTY LIVER

ABNORMAL (LFTs)

ANEMIA

DIARRHEA

IRRITABLE BOWEL SYNDROME (IBS)

INFLAMMATORY BOWEL DISEASE (IBD)

ACID REFLUX (GERD)

GI BLEEDING

LIVER DISEASE

HEMORRHOIDS

CONSTIPATION

OTHER

IF OTHER, SPECIFY:

Offices in San Bernardino, Rancho Cucamonga and Riverside (OFFICE number: 909-360-1111)

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