Consultation Request


This form is specifically for use by providers from other offices requesting a patient consultation with one of our providers. It is not for patient use.

* Required Fields

Patient Name: *
Date of Birth: *
Vision Number: *
Requesting Provider: *
Office Name: *
Reason for Consult: *
Referral Needed? Yes
No
If Yes, Referral Contact:
Consultation Needed: Within 2 Weeks
Next Available
Providers Available:
(Select All Applicable)
Jennifer M. Barbieri, M.D.
Larien G. Bieber, M.D.
James E. Spicher, M.D.
Stephanie Todd, M.D.
Robert A. Tribuzio, M.D.
No Preference
Your e-mail will be received by our referral staff. Paula will call and schedule the appointment with the patient. Please fax all pertinent studies and progress records to Paula at (717) 397-7634.
 
Your Full Name: *
Your Phone Number: *
Your Email: *
 
Questions/Comments:
Verification Code:*
Please input the numbers you see into the box below.
No spaces are necessary.
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General Internal Medicine of Lancaster

2301 Columbia Avenue • Lancaster, PA 17603 • Phone: (717) 397-2738 • Fax: (717) 397-7634

©2017, General Internal Medicine of Lancaster. All Rights Reserved.