Consultation Request - Infectious Disease Consultants Group, PC

Thank you for allowing us to participate in the care of your patient. Please complete the below form or download the attached form and fax to 618-239-9555 ATTN: Erika.

Referring Physician
Physician Phone Number
Physician Fax
Patient Name
Patient DOB
Patient Phone Number
Patient Address (Include City, State, Zip)
Insurance
Policy #
Group #
Referral # (if any)
Diagnosis
Pertinent Medical History
Current Medications
Labs/Diagnostic Reports (Please Fax if unable to attach)
Labs/Diagnostic Reports being sent separately?	Yes No
Form Completed By
Date