HCG REFERENCE SERVICE
REFERRAL FORM

THIS FORM MUST BE PRINTED ON YOUR COMPUTER (select print option), AND THEN COMPLETED AND SENT ALONG WITH SERUM AND URINE SAMPLES, PATIENT HISTORY, AND PAYMENT, IN ALL REFERENCE SERVICE CONSULTATIONS

Name of Patient:____________________________________________________

Patient contact phone number_________________________________________

Date of Birth of Patient_______________________________________________

Most recent hCG Result________________________________________mIU/ml

Date of hCG results__________________________________________________

Laboratory that performed test________________________________________

Managing physician___________________________________________________

Telephone___________________________________________________________

FAX for reports______________________________________________________

Physician's E-mail_____________________________________________________

Please fill out the following:

1. Have you provided serum and urine                                        YES   /   NO

2. Have you include brief history or records                                YES  /   NO

3. Have you included means of payment                                      YES  /   NO
(MAKE CHECK OUT TO: UNM, DEPT OF OB & GYN)

4. Is it acceptable if  your samples are stored
and used for future research and future test                              YES /   NO
evaluations                                                       

While we will provide a receipt and information needed for insurance reimbursement we cannot guarantee that any specific company will completely cover all out-of-pocket costs.