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Lakeland Clinic Outpatient Referral Form

Outpatient Referral Form Lakeland Clinic

  • Referral Source Information

  • Person Making Referral * Required
  • Office Contact Person * Required
  • Patient Information

  • Legal Name of Patient * Required
  • Parent/Guardian Name (if applicable)
  • Insurance Subscriber Name * Required
  • Patient Referred To: Lakeland Clinic Psychiatric Consultation

  • Patient has authorized this referral source to share this form with Pine Rest for the purpose of discussing and scheduling patient's appointment. An additional release of information will be required to discuss treatment.
  • Please note that the following labs will need to be faxed to us prior to the appointment: CBC, CMP, UDS, TSH, Vitamin B12, Vitamin D. If labs are not received prior to the initial appointment, we will need to reschedule the appointment. Labs can be faxed to 877-242-6963.

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