HCG REFERENCE SERVICE
REFERRAL FORM

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

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Name of Patient:______________________________________

Patient contact info___________________________________

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

 

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.