GI REFERRAL FORM DATE: PATIENT NAME : DATE OF BIRTH: (PLEASE COMPLETE THE FOLLOWING OR ATTACH FULL DEMOGRAPHICS) ADDRESS: CITY: STATE: ZIP CODE: PHONE NUMBER: E-MAIL ADDRESS: INSURANCE : MEMBER ID : *CIGNA CONNECT AND CAREMORE NOT ACCEPTED TYPE OF REFERRAL OFFICE VISIT SCREENING COLONOSCOPY NOTE: OFFICE VISITS CAN BE SCHEDULED ONLINE WITH REAL TIME AVAILABILITY AT WWW.COMMONWEALTHGASTRO.ORG DIAGNOSIS/ICD CODE(S): ADDITIONAL INFORMATION: APPOINTMENT DATE (IF SCHEDULED ONLINE): INSTRUCTIONS TO PATIENT (IF APPLICABLE) : REFERRING PROVIDER : SPECIALTY: NPI: PHONE NUMBER: FAX NUMBER: PLEASE ATTACH THE FOLLOWING IF AVAILAB LE : DEMOGRAPHICS MEDICATION LIST HEALTH INSURANCE CARD EXAM NOTES LAB REPORTS CT/ULTRASOUND OF ABDOMEN/PELVIS DR. SCOTT WOOGEN 4000A GLENSIDE DRIVE HENRICO VA 23228 PHONE: (804) 716-6318 FAX: (804) 801-5187