PATIENT INFORMATION

Last Name (required):

First Name (required):

Date of Birth

Phone Number (required):

Other Contact Person or POA (Name & Phone Number), if applicable:

REFERRAL INFORMATION AND SUPPORTING DOCUMENTATION

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

Brief History/Previous Treatments:

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.

• Referral Letter/ History & Physical/ Last clinic note
• Relevant Labs (ALL available CBCs, genetic testing, iron studies)
• Previous Consultation (GI, Hematology, Medicine)
• Relevant Imaging
• List of Current Medications

Request Priority: Urgent - contact hematology provider on call at (505)272-2000 ASAP Routine

Reason:

REFERRING PROVIDER INFORMATION

Provider's Name:

Facility:

Facility Phone Number:

Facility Fax Number:

Direct line to provider: