New Referral

To

Dr Ramin Gohar

From

Date

Can you please supply the following information regarding your patient prior to their appointment.

Name

D.O.B

Letter of Referral (2mb limit)

Operation Report (2mb limit)

Histology/Cytology reports (2mb limit)

Radiology Reports (2mb limit)

Recent blood tests (2mb limit)

Has this patient been seen by any other specialist relating to this or any other condition? If so, please list

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