Refer a Patient

This online form is for physicians and other health professionals to refer a patient to the UCSF Hernia Center. If you are NOT a physician or health professional, please use our Request an Appointment Form.

Please complete the form below to initiate a referral request. Appointments by phone may also be made by calling (415) 353-2161. This is a secure form and any information provided will be handled in strict compliance with applicable privacy laws.

* indicates required field

Patient Information

 
* First Name:
  
* Last Name:
 
* Address:
  
Apartment/Suite No:
* City:
  
* State:
  
* Zip / Postal Code:
  
* Country:
 
* Daytime Phone No:
 
Alternate Phone No:

Email Address:
* Date of Birth:

Example: 02/20/1980
 
* Gender:
 
How did you hear about UCSF?

Referring Provider Information

* First Name:
  
* Last Name:
 
* Address:
  
Office Suite No:
* City:
  
* State:
  
* Zip / Postal Code:
  
* Country:
  
* Office Phone No:
   
Office Fax No:
Cell Phone No:
Pager:
Email Address:

Primary Care Physician Information

* Are you the Primary Care Physician?

If no, please provide the following information (if known).

Name of Primary Care Physician:
Primary Care Physician's Phone:

Insurance Information

Select the patient's medical plan from the dropdown list. If not listed, type the plan into the box “Other”.
* Medical Plan:    
Other:
Group No:
Subscriber No:
Does the patient have secondary or supplemental health insurance?
*Secondary Medical Plan:    
Other:
Group No:
Subscriber No:
* Does the patient have a physician referral?
 

Type of Visit

* Please check all that apply.  



  Other:

Reason For Appointment

Type of Hernia Repair Desired:


Additional information

Desired Physician or Provider

If the patient has a physician or provider preference, please make your selection here.

Desired Physician or Provider:
Has the patient seen this provider before?

Diagnosis

If applicable, select the patient's diagnosis from the dropdown list. If not listed, then type the diagnosis into the box labeled "Other".
Diagnosis:

Other:

Diagnostic Tests

Please check all tests performed to diagnose the patient's condition.


Other:

Treatment History

Have you had a prior hernia repair?
Hernia Repair with Mesh
How many times:
Date(s) of repair:
Unsure of details:
Additional information:
Hernia Repair Without Mesh
How many times:
Dates of repair:
Unsure of details:
Additional information:

Additional Information

Please provide any other relevant information about the patient's treatment in the space below.

Please review the information you have provided above. Then click "Submit". A UCSF Patient Coordinator should be contacting you within one business day. Should you have any additional questions or concerns, please contact the clinic directly at (415) 353-2161.

*  Please type the verification characters below into the yellow box and press "Submit". You will then receive a confirmation message on the screen. Please do not press “Submit” more than once.

 


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