Fillable Form 1: FAX TO 406 435-8482 Note: All (Billings Clinic)

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Form 1: FAX TO 406 435-8482 Note: All (Billings Clinic)

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Revised 9/24/2018 v9 jms/dlg
Patient Name: DOB:
1
Please write the clinical question to be addressed in this box:
Is this a new diagnosis?
Yes No
2
Note: All referrals must include patient demographics, pertinent notes and medication
list.
Incomplete referrals will no
t be held longer than 5 business days.
3
Choose referral diagnosis and description
DIABETES MELLITUS
Choose from both dropdowns:
Is this referral for (check one):
Management (team including MD/NP/PA and CDE)
• Seeking insulin pump and/or continuous glucose monitor
(will meet with provider and CDE for pump pathway)
• Needs CDL paperwork?
Education ONLY (will not be seen by provider, will be seen by CDE
only)
Please provide most recent CMP, urine creatinine/albumin ratio, lipid profile, BMI,
dates of last foot and eye exam, and A1c FROM WITHIN 90 DAYS.
THYROID
Choose appropriate from dropdown:
MUST have TSH within last 90 days. Please also provide most recent free T4,
antibody studies, imaging or pathology results with images.
ADRENAL
Please provide most recent labs, imaging as available.
PARATHYROID / ABNORMAL
CA / OSTEOPOROSIS
Most osteoporosis referrals will be seen initially by NP. Please provide most
recent PTH, Vitamin D if available, Ionized calcium, CMP, DXA scan, imaging
results.
PITUITARY / PROLACTIN
LEVELS / ACROMEGALY /
EMPTY SELLA
Please provide most recent labs, imaging results.
PCOS
Please provide most recent labs (please note: fertility/menstrual concerns should be
referred to Reproductive Endocrinology or OB/GYN)
HYPOGONADISM
Please provide 2 most recent a.m. testosterone and a PSA.
WEIGHT
Weight concerns will be handled through either our Weight Smart or Metabolic
Surgical pathway, which include comprehensive metabolic evaluation.
Please specify interest in surgical non-surgical program.
TRANSGENDER HEALTH
Please provide most recent labs; and mental health provider notes if available
Please note: This is for consult only. We do not provide surgical services
Our apologies, but due to patient volume, Billings Clinic Endocrinology does not currently provide care for menopause, reproductive
hormone replacement (except male hypogonadism), thyroid patients who are euthyroid on therapy, or patients with diagnoses not
specific to endocrinology (i.e. "fatigue" without underlying pathology).
• Please be advised that services may be provided by an NP or PA in our department.
Referring Provider's Name: Date_______________
REFERRAL
FORM
FAX TO 406 435-8482
D
IABETES
,
E
NDOCRINOLOGY
&
M
ETABOLISM
C
ENTER
Hyperthyroid
Controlled
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Form 1: FAX TO 406 435-8482 Note: All (Billings Clinic)

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Completed 31 January 2021

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