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(559)-431-4007
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Make a Referral
Request Appointment
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What We Treat
Location
Contact Us
What We Treat
Location
Contact Us
Menu
What We Treat
Location
Contact Us
Home
Make a Referral
Request Appointment
Home
Make a Referral
Request Appointment
Make a Referral
Nighat Sarwar M.D.
7407 N. Cedar Ave #103
Fresno, CA 93720
Phone: 559-431-4007
Fax: 559-431-3357
Patient Referral
IMPORTANT
:Include all of the following information required to process referral
Patient Demographic
Most recent progress note
Recent labs w/calcium (osteoporosis patients)
Prescription(dose and frequency included)
Pre-Medication order
Insurance cards
Recent bone density scan (osteoporosis patients)
PATIENT INFORMATION
Patient Name
Primary Phone:
DOB:
Age
Sex
Select
Male
Female
Home Address
Referring Provider:
Contact Person:
Phone
Fax
INFUSION THERAPY REQUESTED
Tysabri
IVIG
Soliris
Vyepti
Belatacept
Ocrevus
Rituxan
Entyvio
Ultomiris
Prolia
Leqvio
Solu-Medrol
Other:
Frequency:
Dose
Diagnosis (include ICD-10):
PRE-MEDICATIONS REQUESTED
Benadryl (IV or PO)
Tylenol (PO)
Solu-Medrol (IV) Other
Physician Signature:
Date:
Submit