Surgical Referral Form

1. To refer a potential client for surgery consultation, please complete this form and return it, along with a copy of any medical records, recent lab work, and diagnostic imaging.

2. Please make sure the patient has not had anything to eat after 10 pm the night prior to the scheduled surgery consultation. (Water is ok, this does not apply to Diabetics).

3. Following the surgery consultation, a summary of all findings, diagnostic test results, and treatment recommendations will be faxed or emailed to you.

If you have any questions or concerns, or if you would like to discuss the case directly, please do not hesitate to contact Dr. Wormser at any time at 518-761-2602

Client Information

Full Name(Required)
MM slash DD slash YYYY
Patient Name(Required)
Sex(Required)

Referral Information

Name(Required)
Drop files here or
Accepted file types: pdf, doc, docx, Max. file size: 20 MB.
    Should this patient need additional diagnostic tests or treatments would you like us to initiate treatment?(Required)
    This field is for validation purposes and should be left unchanged.