Rheumatology Referral
Referral to Rheumatology - either doctor Carmen Perez-Masuelli, MD Leslie Wilson, MD
Patient Name
DOB
Patient phone
Patient's primary insurance Preauth required?
Referred by Dr.
Reason for referral
URGENCY: Within the next 3 months Within the next 3 weeks
Office contact
Contact phone
Written report: By fax By mail
Fax number, if applicable: