Referral Forms
To provide a full spectrum of office support, Saint Agnes offers quick links to several referral forms. To download a form, simply right-click on the title of the document and select the “Save link as” or “Save target as” option.
Referral Forms:
- Bariatrics New Patient Referral Form
- Cardiovascular Diagnostic Services Order Form
- Good Health Prescription (Health Programs Guide)
- Home Health and Hospice Express Referral Form
- Hyperbaric Requisition Order Form
- Imaging Services Order Form
- Lab Services Order Form
- Lung Screening Order Form
- Mammography Physician Order Form
- Neurodiagnostic Services Order Form
- Nuclear Medicine Order Form
- Outpatient Infusion Order Form and Instructions
- Symptom and Support Clinic Referral Form
- Wound, Ostomy and Hyperbaric Center Order Form
Saint Agnes Care Referral Forms:
- Bariatric Surgery
- CT Surgery
- Pain & Spine
- Orthopaedic Institute
- Outpatient Imaging Center + Patient Instructions (OPIC)
- Surgical Services
Pre-exposure Prophylaxis:
Call (559) 450-5656 to schedule your patients for pre-exposure prophylactic treatment. Then download and complete the orderset below. Once completed, fax orderset directly to the Infusion Room, 559-450-2224. Appointments with incomplete orders will NOT be confirmed.
If you would like to request any additional referral forms not listed, or if you would like a pad of referral forms delivered to your office, please call Communications at SaintAgnes@samc.com.
Additional Contacts
For additional information or questions regarding the following areas, please contact the department directly.
Medical Staff Office
Direct: (559) 450-3631
Fax: (559) 450-3370
Medical Records
Direct: (559) 450-3327
Fax: (559) 450-3771
MedicalRecords@samc.com
Scheduling
Direct: (559) 450-5656
Fax: (559) 450-5288
Centralized.Scheduling@samc.com