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Get IN Referral Order for Urologic Services 2012-2024

________________ Tax ID: _____________ Office Phone: ____________________ Office Fax: ______________________ Email: ______________________________________________________________________________ To make a referral, please complete the following information and fax form to 317-807-0140. We will contact your patient to schedule an appointment and notify you of the date and time. PLEASE FAX PERTINENT PATIENT MEDICAL RECORDS AND A COPY OF THE INSURANCE CARD TO EXPEDITE THE PROCESS. PATIENT INFORMATI.

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