On-line Referral Form

Doctor - In order to facilitate the process of patient referrals between your office and ours, we have created this on-line referral form. If it is easier for you and your staff, please feel free to continue to use the paper referral pads just as you have in the past. But, if you want to send us information via the Internet, you can follow the steps outlined below for on-line referral:

 

 

 

 

#1- Fill out the fields below about your patient and reason for referral.

#2- Give your patient our phone number (303) 832-4867 and web address: www.poulosandsomers.com

#3- Instruct your patient to call our office to set up an appointment and to explore the website to learn more about our office and to begin the process of patient education.

#4- If we don’t hear from your patient within 1-2 weeks, we will call them to follow-up.

* Radiographs and charting can either be sent via email to: contact@poulosandsomers.com or given to the patient as a hard copy to bring in at their visit.

Date:
Name of Referring Doctor:  
Doctor's Phone Number:  
Doctor's Email:  
Patient's Name:  
Patient's Phone Number:  
Area(s) of Concern:
Comments?: