Without this completed form, we cannot complete your outside consultation request.

CHECKLIST FOR OUTSIDE CONSULTATION

PATIENT NAME: ____________________________________ DATE: _____________

Please refer to Guidelines for Outside Consultation on Page 1 for details.

REQUIRED:

_____ This Signed Checklist

_____ Cover Letter

_____ Current MRI Films

_____ Typed MRI Report

_____ Current X-Rays

_____ Typed X-Ray Report

_____ Return Instructions for Images

_____ Postage for Return of Items OR Fed Ex Number

_____ Contact Phone Number(s):

            (_______)____________________________

            (_______)____________________________

OPTIONAL:

_____ Operative Reports, Photos, or Video of Prior Surgery

_____ Physician Reports

Please sign below that ALL required items are included in your package.

X_______________________________________________

The Stone Clinic
3727 Buchanan Street
San Francisco CA 94123
415-563-3110