Medical Discounts, Inc.
Phone
(888) 380-6337
Email –
MedicalDiscounts@aol.com
Physicians, Chiropractors, Podiatrists or Dentists
Print this form, fill it out & fax it to 866-380-6337
Once we receive it, we will contact the patient & schedule the procedure.
Patient Name: _______________________________________________________________ Today's Date: _________________________
Patient Address: _____________________________________________________________________________________________________
Patient Phone: ___________________________ Patient Cell Phone: __________________________
Referring Provider (Print): ______________________________________________________________
Provider Phone: ( )________________________ Provider Fax: ( )_______________________
Examination Requested: _________________________________________________________________________________________________
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Clinical Impression: _____________________________________________________________________________________________________
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Referring Provider Signature: ___________________________________________________ Date: _________________________________
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Report Results (check all that apply)
_____ Phone Report to: ________________________________ ` ______ Fax Report to:__________________________________
_____ Send Additional Reports to the following:
____________________________________________________________________________
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_____ Send Films (CD) With Patient