Consult Request Form

This form must be submitted by qualified health care providers only. We do not accept consult requests directly from patients. Once the form is submitted we will contact the patient and arrange for an appointment. All online information is protected with our SSL certificate. Please see HIPAA guidelines and our online disclaimer.

*  Indicates fields are required
 
Date of Request: 
* Referring Physician: 
* Office Contact: 
* Referring Physician Address: 
* City: 
* Phone: 
* Fax: 
* Patient Name: 
* Birth Date: 
* Patient Address: 
* City, State, Zip: 
* Patient Phone: 
* Primary Insurance: 
Secondary Insurance: 
 
Brain Spine Nerve/Pain
Brain Tumor Cervical Herniated Disc Carpal Tunnel Syndrome
Aneurysm Cervical Stenosis Ulnar Neuropathy
Trauma Lumbar Herniated Disc Brachial Plexus Injury
Carotid Stenosis Lumbar Stenosis Intrathecal Pump Placement
Hydrocephalus Neck Pain Spinal Cord Stimulator
Seizure Surgery Back Pain
Deep Brain Stimulation Radiculopathy
Trigeminal Neuralgia Myelopathy
 
Please Check Below if any studies listed have been obtained:
XRay  
CT  
MRI  
Angiogram  
EMG/NCS  
Other  
 
Please select which doctor you would like your patient to be seen by: 
James Chadduck, MD  
Allan Fergus, MD  
Patrick Ireland, MD  
Steven Schopick, MD  
Lee Selznick, MD  
First Available Doctor  
 
   

 

Thank you for the consultation request.

We would greatly appreciate a letter or recent office note outlining the clinical history regarding this consultation as well the dictated reports from any studies obtained. If the studies were not obtained at Winchester Medical Center please have the patient bring hard copies or a disc to their appointment.  Please fax this information to (540) 450-1797.

Thank you for this referral.

If you need further information please call (540) 450-0072 extension 2308.