Patient MRN:_______________________________

Patient name:______________________________

Patient address:_____________________________

Patient phone :_____________________________

Primary MD:__________________Beeper/phone____________

Diagnosis/Reason for referral:

Past Medical History:

Estimated length of treatment:

Current Meds (dosage):
               1. Coumadin   _______  mg (at time of discharge)
 
 
 
 

  Maintain INR at:_________________________________
 

Referring MD (if different from PMD):________________