Microsoft word - one & only referral form.doc

Referral Form
Dayton Interventional Radiology
3075 Governor’s Place Blvd. Suite 120 Dayton, OH 45409
Phone: (937)424-2580
Date: ____/____/____ Fax: (937)424-2581

Patient Name: ___________________________________________DOB:____/____/_____
Soc. Sec. #_______-_________-____________ Insurance ______________#_______________________
Home Phone: _______________Work Phone: _________________Cell Phone: ____________
Address _______________________________________________________________________________
Recent Radiology studies_________________________________________________________________
Patient notified to bring films YES_____ NO FILMS_______
Reason For Referral:
________________________________________________________________________
__________________________________________________________
Where: _______________________________________When:_____________________
***Patient must be notified to bring Films/CD with them to appointment. If they do not have Films/CD,
the referring office is responsible for requesting them and having them sent to our office. Thank You***
Referring Physician: _______________________________________________________
Physician Signature: ________________________________________________________
CC: ____________________________ Office Contact: ____________________________
Office Phone: _____________________ Office Fax: ______________________________
Please Fax with Form:
• Medical Records (H&P, all reports, and laboratory data)
• Insurance Cards
• Photo ID
• C-9 form for Workers Comp
***If patient is being scheduled for a procedure, Referring office must give
Patient Instructions:
1. Do NOT have anything to eat or drink after midnight the night prior to your procedure OR 6 hours prior to
procedure.
2. You MUST have someone to drive you home after your procedure.
3. Do take heart or blood pressure medications with a small sip of water the morning of your procedure.
4. Do NOT take ANY pain medication the day of your procedure unless otherwise instructed.
5. STOP blood thinners (Coumadin, Plavix, Pletal, Aspirin, Ibuprofen) 4 DAYS prior to your procedure. IF YOU ARE
HAVING A VENOGRAM, FISTULAGRAM, DECLOT OR VENOUS ABLATION PROCEDURE YOU MUST
CONTINUE TAKING (COUMADIN, PLAVIX, PLETAL, ASPIRIN, IBUPROFEN ) DO NOT STOP !
6. Do NOT take your diabetes medication the day of your procedure.
7. Wear comfortable clothing.
8. Arrive at least one hour prior to allow time for registration and procedure preparation.
9. Bring your insurance &/or workers comp information along with a photo ID (drivers license).
10. Plan to pay required co-pays @ time of service.
11. To insure the highest quality procedure in a safe environment, we are unable to provide child care services for you.
12. Please do NOT bring unattended children to the center.
13. Do to limited space; please limit the amount of family members in attendance to 1 or 2 people.

Fax to: (937)424-2581

Source: http://www.daytonir.com/Portals/0/pdf/Referral_Form_Fillable.pdf