Onslow Medical Specialties Clinic –Lung & Sleep Disorders Clinic Eusebio Desuyo, md, mba, mph



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Onslow Medical Specialties Clinic –Lung & Sleep Disorders Clinic

Eusebio Desuyo, MD, MBA, MPH

123 Pompano Place, Suite 100

Jacksonville, NC 28546

Phone 910-455-9398

Fax: 910-455-5407

www.omsclinic.net

Pulmonary/ Sleep Disorders Clinic Referral
Patient: _____________________________________SS# ______________

DOB: ___________ Height: ______(feet/inches)Weight :___________(lbs)

Address: ________________________City/State____________ Zip:______

Home Phone:____________________ Work/ Cellphone:_______________



We will need fax copies of patient’s health insurance card (front & back ), Driver’s License/State ID, and History & Physical Notes/Progress Notes/ Medications list.
Referring Physician: _______________________________UPIN:______

Referring Physician’s Address:____________________________________

___________________________________

Phone & Fax _____________________________________


Reasons for Pulmonary/ Sleep Disorders Clinic Referral:
____________________________________________
____________________________________________


I authorize Onslow Medical Specialties Clinic – Lung & Sleep Disorders Clinic to see above patient for further evaluation and treatment, as a medical necessity.

Referring Physician Signature:___________________ Date:___________


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