Cook Children’s Endocrine and Diabetes Services: Abilene | Denton | Fort Worth | Hurst | Lewisville Mansfield | San Angelo | Southlake | Waco 1-866-266-7948 new patient scheduling line 682-885-7960 main phone | 682-885-1327 fax Date________________________________ Endocrine and Diabetes referral /order Patient name _________________________________________________________________________________ DOB_ _________________________________________ Address _ ___________________________________________________________________________________________________________________________________ Guardian name_ _____________________________________________________________________________________________________________________________ Contact numbers work_ ______________________________________ home_____________________________ cell______________________________________ Language preference English Spanish Other_______________________________________ Reason for referral ___________________________________________________________________________________________________________________________ Referring physician ________________________________________________________________ phone_______________________ fax________________________ Primary insurance name_ ___________________________________________________________________________________ HMO PPO POS ID #________________________________________________________________________________ Group #_________________________________________________ Subscriber name____________________________________________________________________ DOB____________________________________________________ Authorization number _ __________________________________________________________ Appointment priority emergent 1-3 weeks routine Thank you for allowing us to participate in the care of your patient. In order to make the first visit more productive, we ask that you send any recent lab or X-ray reports, as well as the patient’s growth chart with your referral. Lab/X-ray reports included: ❏ yes ❏ no ❏ N/A Growth chart included: ❏ yes ❏ no ❏ N/A Insurance card included: ❏ yes ❏ no Comments:_________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Preferred location: ❏ Abilene: Susan Hsieh, M.D. | Teena Thomas, M.D. ❏ Denton: Jill Radack, M.D. | Joel Steelman, M.D. | Michael Willcutts, M.D. ❏ Fort Worth: John Dallas, M.D. | Alex de la Torre, M.D. | Susan Hsieh, M.D. | Jill Radack, M.D. | Joel Steelman, M.D. | Teena Thomas, M.D. Paul Thornton, M.D. ❏ Hurst: John Dallas, M.D. | Teena Thomas, M.D. | Paul Thornton, M.D. ❏ Lewisville: Michael Willcutts, M.D. ❏ Mansfield: John Dallas, M.D. ❏ San Angelo: Alex de la Torre, M.D. | Joel Steelman, M.D. | Don Wilson, M.D. ❏ Southlake: Jill Radack, M.D. | Michael Willcutts, M.D. | Don Wilson, M.D. ❏ Waco: John Dallas, M.D. | Michael Willcutts, M.D. | Michael Willcutts, M.D. | Don Wilson, M.D. Physician signature_______________________________________________________________________________________________________________________ Please fax this form to 682-885-1327 06/13