Referral Request

Please use this form to request a referral to a specialist's office. We require 7-10 business days to process your request. Referrals will be sent to the specialist's office in time for your appointment. Emergency referrals must be called to the referral office at (717) 397-2738.

* Required Field

Please provide the following contact information:

Contact Information

Name*
Date of Birth*
Home Phone*
Work Phone
Email

Name of your Provider*

Name of Your Insurance Company*

Reason for Referral (Diagnosis)*

Who Were You Referred To*

When Is Your Appointment*

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© 2008 General Internal Medicine. All Rights Reserved.
2301 Columbia Avenue Lancaster, PA 17603
Phone - 717.397.2738 Fax - 717.397.7634

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