If we have referred a patient to your office and you’d like to request medical records, please fill out the form below. We will assist you as quickly as possible. Thank you.
Please click button below for a Printable PDF Referral Request form.
Do NOT use form for kidney stones or other emergency –
please call (662) 432-0700 for an appointment.
To expedite your referral the following documentation is REQUIRED: CLINIC NOTES, HISTORY & PHYSICAL, LABORATORY RESULTS, RADIOLOGY REPORTS, PERTINENT OPERATIVE REPORTS, PATIENT DEMOGRAPHICS, FRONT AND BACK COPIES OF INSURANCE CARDS. Please note your request for referral will not be processed until records are received. Please fax pertinent documentation with this referral form to: (662) 842-0568.