JENNIFER M. LEE FNP, LLC
1314 S. King Street, #604
Honolulu, HI 96814
808-546-9544
REFERRING PHYSCIAN INFORMATION:
Referring Physician Name
Practice Name
Physician Phone Number:
Physician Email:
PATIENT INFORMATION:
Full Name
Date of birth
Phone Number:
Email
*
Preferred Method of Contact
Cell Phone
Home Phone
Email
REASON FOR REFERRAL:
Service Requested:
Exomind
IV Therapy
Incontinence/Emsella
TMJ
Weight Management
Primary Reason for Referral:
CONSENT TO CONTACT:
I confirm that I have obtained the patient’s permission to share their information for the purpose of referral and care coordination.
Yes
Physician Signature
Clear
Date
Submit