Non Malignant / Classical Hematology Referral Form

PATIENT INFORMATION


REFERRAL INFORMATION AND SUPPORTING DOCUMENTATION

*If the reason for referral is anemia, please specify the underlying cause, if uncertain, include what work up was done.




Referral Packet

Please include the following information in the referral package. Please fax to (505) 272-5458. Incomplete referral may delay appropriate triage and referral time.



REFERRING PROVIDER INFORMATION