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Outpatient Consult Request

To

Referred to:____________________________________________________________________________
(Specialty Clinic or Service)

Physician Name / Location _______________________________________________________________

(Optional)

Referring Physician: _______________________________________ Office Name:__________________

(Please Print)

Office Contact: _______________________________________ Phone#: (____)____________________

From
Fax#: (______)_____________________________ E-Mail Address: _____________________________

Please Contact Our Office With Clinic Appointment Date/Time

Physician Name:___________________________________________ Office Name:_________________
(Please Print)

PCP
(If different from
Referring)

Office Contact: _______________________________________ Phone#: (____)____________________

Fax#: (______)_____________________________ E-Mail Address: _____________________________

Please Contact Our Office With Clinic Appointment Date/Time

Name: Last__________________________________ First_______________________________________
Patient
Information

UMHS Medical Record # (if available): _____________________________

Gender:

DOB:

__________

Telephone: Home (____)______________ Work: (____)______________Other: (____)_________________

Address:____________________________ City:_____________________ State:________ Zip:_________
Mother's Name:________________________________
Other Contact
Information
(if applicable)

Father's Name:____________________________

Other (please explain):____________________________________________________________________

Telephone: Home(____)_______________ Work: (____)______________Other: (____)________________
Insurance: ______________________

Insurance
Information

Medicaid:
Auto Accident?

HMO
Y

Other
N

HMO

PPO

Traditional

Medicare

None

Medicaid Insurance Plan: _________________________________

Date of Injury _________ Work Comp?

UMHS Consult Request Guidelines

Diagnosis and
Reason for
Consult or
Therapy

POS

www.med.umich.edu/umconsults

Date of Injury ______

Appointment Requested:
Next Available
Within 2 weeks
Within 1 week
Other ____________________
Second Opinion?

Yes

No

Physician Signature: (Required for PT and diagnostic test only)

Requesting
Physician

____________________________________________________________________________________________________
(Signature)

(Date)