Physician Referral Form

PHYSICIAN REFERRAL FORM

Rex Sherer, M.D., William “Charlie” Braswell, M.D., Elizabeth L. Newman M.D., Tim Sahawneh, M.D.

644 2nd Street NE Suite 206 (2nd Medical building behind Arby’s)
Alabaster, AL 35007
Phone# 620-9065
Fax# 664-5510 or 620-9051

*Please note that this referral form is for general surgical consults and not for weight
loss surgery consults. Please have the patient contact us directly to discuss a
bariatric consultation.

Please complete this form and fax back with DEMOGRAPHIC INFORMATION
and PERTINENT MEDICAL RECORDS to (205) 664-5510 or 620-9051

Today’s Date:

Patient Name:

DOB:

Patient’s home #

Work#

Cell#

Insurance Co.

Contract/ID#

Referring Physician:

Office contact person:

Phone/Fax:

Referring Diagnosis:

Please check here if no labs or diagnostics were done to identify condition.

Your patient will be contacted within 48 hours of receipt of this form, face sheet, and medical records to schedule an appointment. If the patient needs to be seen within three (3) business days, PLEASE do not hesitate to call the office directly to schedule an appointment

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Appointment Date:

Time:

PHYSICIAN REFERRAL FORM

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Cahaba Valley Surgical Group, 2023. All rights reserved.

Cahaba Valley Surgical Group, 2023. All rights reserved.