Referring Physicians

Dear Referring Physician,

Allergy, Asthma & Sinus Center, P.A., welcome the privilege of working with you on the evaluation and care of your patients. We hope that we will be able to enhance your practice through prompt consultations and clear communication. We will fax you a report of our consultation the same day that we see your patient in consultation via our Meditab IMS electronic medical records system. Therefore, you will have up to date information about your patient without any delay.

We welcome your calls, and our office will do their utmost to accommodate your patients in a timely manner. Calls from physician offices will be given priority based upon professional opinion for either "same day" or "next day" booking. We look forward to the opportunity to participate in the care of your patients.

Sincerely,
Dr. Judge & Staff

Referring Physician's Form | Download Now

Referring Physician's Form

*Date: (yyyy-mm-dd)
*Patient Name:
*Phone:
*DOB:
*Email:
*Insurance ID#:
*Insurance Group #:
*Referring Practice Name:
Referring MD / PA / NP:
Fax:
NPI:
Medicaid Access # if applicable:

Reason for Consultation:

 Asthma  Skin Rashes/Eczema  Urticaria & Angiodedma
 Allergy Rhinitis  Recurrent Cough  Drug Allergy
 Recurring Sinusitis  Food Allergy  Immune Deficiency
Insect Stings/Anaphylactic Other 
Please Fax the relevant office notes, test results or X-Rays for this patient
Name of Referral Coordinator:
*Verification Code:
captcha
Verification code is not case-sensitive
 
All fields with * are mandatory