Pediatri
c
Gastroenterology
of Richmond, PC
Consultation Request Form
Date: ________________________
Fax: _________________________
ATT: ________________________________________________
Patient Name: _________________________________________
Date of Birth: ____________________
Dear Requesting Provider:
We have received your request for a consultation or referral for this new patient.
Please complete the attached cover sheet as indicated and use as the cover sheet when
faxing medical records to the clinic. Fax to the number indicated on the consultation
request form. Please include relevant medical records.
Thank you.
Juan F. Villalona, MD, FAAP
Pediatric Gastroenterology of Richmond, PC
The information contained in this message may be privileged and confidential, and protected from disclosure. If the reader of this
message is not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication, is
strictly prohibited. If you have received this communication in error, please call (804) 888-PEDS (7337).
Pediatric Gastroenterology of Richmond, PC
The Highland II Medical Office Building - 7229 Forest Avenue, Suite 106 - Richmond, VA 23226
Tel. 804.888.PEDS (7337) – Fax 804.888.9738
www.pedsgirichmond.com