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Refer a Patient

Patient Name *:
DOB *:
Insurance Carrier *:
Primary complaint (click all that apply) *Typical GERDLPR/pulmonary issues/sleep apneaHiatal hernia/paraesopahgeal herniaAchalasiaGastroparesisBarretts esophagusReoperationOther:
Best Contact *:
Alternative contact:
Testing onlyTesting and consultation
Provider requesting *:

Please fax test result and clinic notes to 303-788-8982 to accompany this referral.

What is the best way to send results to you *:
Mail Email Fax

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10099 Ridgegate Pkwy Suite 460, Lone Tree, CO 80124



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