CALL (360) 977-7815 FOR AN APPOINTMENT ~ OPEN MONDAY - FRIDAY 8AM TO 5PM

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PRIMARY CARE OR OTHER SPECIALTY PHYSICIANS IN THE VANCOUVER, WA AREA WITH A PATIENT IN NEED OF A REFERRAL OR TREATMENT OF AN ANKLE OR FOOT CONDITION CAN QUICKLY SUBMIT THE REQUEST BELOW TO EFFICIENTLY AND PROMPTLY SECURE AN APPOINTMENT.

OUR STAFF WILL CONTACT YOUR OFFICE THE SAME BUSINESS DAY TO SET UP AN APPOINTMENT FOR YOUR PATIENT.

IF AFTER HOURS OR IF YOU WOULD LIKE TO SPEAK TO ONE OF OUR PHYSICIANS IMMEDIATELY, PLEASE CONTACT OUR OFFICE BY CALLING (360) 977-7815.

 

CONSULTATION ONLY/SECOND OPINION (NO TREATMENT)

ZARKO KAJGANA, DPM

PATIENT INFORMATION

ELLEN WENZEL, DPM

FIRST AVAILABLE DPM

CONSULTATION AND TREATMENT/ TRANSFER OF CARE

DIAGNOSIS OR PERTINENT SYMPTOMS

NAME

GENDER

BIRTH DATE

ADDRESS

CITY

NUMBER

PROVIDER

PRACTICE NAME

PHONE

CONTACT NAME

FAX

REQUESTED PROVIDER

TYPE OF REQUEST

PHONE NUMBER

INSURANCE CARRIER

POLICY NUMBER

PRIMARY POLICY HOLDER

CONSULTATION INFORMATION

AUTHORIZATION INFORMATION

NUMBER OF VISITS

REQUESTING PHYSICIAN/PROVIDER INFORMATION

SECONDARY CARRIER