GASTROENTEROLOGY REFERRAL FORM
GI LAB at the University of Illinois Medical Center

1740 West Taylor Street, Room 2142 UICH

Chicago, Illinois 60612

312-996-3801 (T)   312-413-1557 (F)


Date:                                       

Attn:  General Referral        Dr. Russell Brown       Dr. Allan Halline        Dr. Rama Venu

REFERRING DOCTOR INFORMATION

Name:                                                                                                                                  

 

Practice/Clinic Name:                                                                                                            

Office Address:                                                                                                                     

City, State, Zip:                                                                                                                      

 

Phone:                                                                                                                                  

Fax:                                                                                                                                      

E-mail:                                                                                                                                  

 

PATIENT INFORMATION

 

Patient’s Name:                                                                                                                    

Contact Number:                                                                                                                   


Insurance Name:                                                                                                                   


Insurance Policy #:                                                                                                                

Patient Notes/Medical Illness:                                                                                                

                                                                                                                                            

 

                                                                                                                                            


We are referring this patient for the following procedure:

                    EUS                                                 ERCP
                                                               

                    Other (please specify):                                                                                   

 

Level of Urgency (please contact):

                    Schedule immediately                        < 2 wks                          > 2 wks

 

 

If you have any questions or need to immediate assistance, please call our nurse coordinator,

Sandra Bernklau, RN at  (312) 413-0223 or (312) 996-3808.