PATIENT REFERRAL

Completed Paperwork


Medication List (We will be happy to photocopy it for your file)


Photo ID


Insurance Card


Parent or Guardian if you are under 18-years of age (or a completed consent form available on our website)

WHAT PATIENTS SHOULD BRING TO THE APPOINTMENT:

REFERRAL GUIDELINES

  1. Please include the most recent history and physical or office note
     

  2. Please include most recent imaging studies. EPFA has access to Mercy and CDI hospitals. If images are only available on a disc, the patient should bring these in to load into our system.
     

  3. Please indicate your preferred method of contact for any patient related issues.

ADDITIONAL INFORMATION FOR PATIENTS IS AVAILABLE HERE.

ONLINE PATIENT REFERRAL

If you wish to submit your referral information online, please fill in the following form and someone will be in touch with you after submission. Podiatry