Physician Refferal Form - GI Doctor

“Thank you for your trust in Dr. Berookim and the Gastroenterology Institute of Southern California.Please kindly fill out the referral form below and we will contact your patient as soon as possible.Or, you are welcome to call our office to speak to someone directly.310.271.1122.

Our aim is to not only provide our patients with exceptional GI Healthcare, but also our goals are to work proactively with our physician partners to ensure they are kept up to date on all tests, treatments and results regarding their patients.Thank you.”

Patient information fields:

Patient Name*

First Name

Last Name

Date of birth

Phone

Physician information fields:

Referring Physician*

First Name

Last Name

Best number to reach physician

Physician email*

Diagnosis / Reason for Referral*