Dr. Gerald B Harris, II

Referral to Specialist Dr. Gerald B Harris, II D.O. 623-977-0700 / 877-221-8094

Patient Name DOB Patient Phone Number Patient Cell Number Referred to Specialty Phone Address Fax Diagnosis/Complaint Insurance Subscriber ID/Policy Group Number Secondary Subscriber ID/Policy Group Appointment Requested:

PLEASE CALL THE PATIENT AND SCHEDULE APPOINTMENT. If you have any questions, please call our office Thank you see seeing our patient!

Date of Referral Staff Number of Visits Provider