Date: _________________
EXTERNAL REFERRALS
University of New Mexico Hospitals
UNM Vein & Cosmetic Center (UNM Medical Group) Consult Request
Thank you for your referral. UNM Vein & Cosmetic Center accepts most insurance. Fax completed
form to UNM Vein & Cosmetic Center @ (505) 272-3527. Should you have any questions, please
contact the UNM Vein & Cosmetic Center (UNM Medical Group) @ (505) 272-8346.
Patient Name: _________________________________________________________
DOB: ______________
Patient Phone Number/s: ________________________________________________
Patient Language Preference: _____________________________________________
Referring provider/clinic: _______________________ / _______________________
Primary Care Provider: ___________________________________________________
Referring Clinic Address: _________________________________________________
Referring Clinic Phone/Fax Number:______________________/__________________
__________________________________________
(Provider Signature)
Referring information checklist:
□ Referral Face Sheet (with complete demographics)
□ Current Medication List
□ Copy of Insurance Card
□ PA Requested
Priority:
□ ASAP
□ Routine – Please call 272-8346 if you are requesting a same day appointment
Please
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choose the appropriate reason for the consult:
Varicose veins
Spider Veins/Sclerotherapy
Reconstruction after Mohs Surgery
Blepharoplasty
Breast Reconstruction
Botox/Fillers
Other: ___________________
CPT Code: _______________________________ ICD 9 Code:_________________________________
Please attach additional information that you believe would assist us in providing the best care to your patient.