GYNECOLOGY REFERRAL FORM

GYNECOLOGY REFERRAL FORM

FAX: 540-683-8494

PATIENT INFORMATION

Last name*

First name

DOB*

//

Telephone*

Email*

REFERRING PHYSICIAN

Physician Name*

Specialty*

Telephone*

Fax*

Office Address*

REASON FOR REFERRAL

Gynecology*

AAnnual health evaluation

BPap smear, Cervical cancer screening

CColposcopy

DContraception management

EIUD insertion/removal

FEndometrial biopsy

G Menopause management

H Abnormal uterine bleeding

IFibroids/polyps

JMenstruation dysfunction / amenorrhea

KPolycystic Ovarian Syndrome (PCOS)

LSonohysterograms (evaluation of uterine cavity and tubal patency)

M Genital prolapse/urinary incontinence

N Ovarian cyst/tumour

OInfection / STDs

PPelvic pain / endometriosis / dysmenorrhea

QGenital malformation

RVulvar/vaginal cyst/tumour

SOther

Gynecology (other)*

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