Referral Form

1740 St. Julian Place Columbia, SC 29204 Phone: 803-256-3534 Fax: 803-254-7032
ERIC HORST, MD MARJAN KAREGAR, MD LAURA LABOONE, MD
JANELLE HINSON, PA-C MEREDITH EVERETT, FNP

PLEASE COMPLETE ALL FIELDS
DATE*

MonthDayYear
DR TO REFER TO:*
Patient Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DATE OF BIRTH*

MonthDayYear
GENDER*
RACE*
LANGUAGE*
HOME PHONE*
CELL PHONE
WORK PHONE
EXT
SOCIAL SECURITY NUMBER*
HEALTH INSURANCE COMPANY*
INSURANCE ID #*
SECOND INSURANCE COMPANY
AUTHORIZATION NUMBER*
1. PLEASE FAX LABS, OFFICE NOTES, COPY OF INSURANCE CARD, AND AUTHORIZATION.
2. PLEASE INFORM PATIENT TO BRING ACTUAL FILMS TO THEIR APPOINTMENT.
3. PLEASE ALLOW 2-3 DAYS FOR APPOINTMENT.
YOUR OFFICE WILL BE NOTIFIED BY FAX AND PATIENT BY PHONE/MAIL WHEN APPOINTMENT IS SCHEDULED.

CLINICAL INFORMATION: All referrals over 20 pages should be mailed to our address.
REFERRING PHYSICIAN*
OFFICE EMAIL ADDRESS*
example@example.com
OFFICE ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CONTACT PERSON*
NPI#*
TELEPHONE*
FAX #*
Please enter a valid phone number.
CONSULT REASON*
IS THE PATIENT PREGNANT?*

YESNO
EDD?

MonthDayYear
Date
HAS PATIENT BEEN NOTIFIED OF DIAGNOSIS (Type Y for YES or N for NO*
ATTEMPTED TO REACH PATIENT BUT COULD NOT REACH (Type Y for YES or N for NO*
Please send the records that are relevant to the diagnosis only.

Thank you for your kind referral to Laurel Endocrine and Thyroid Specialists, PA
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