Name of Professional

Title: Dr.

Last Name

MI

First Name

MD, PhD

Address

Address 2nd

City / State / Zip

City

State

Zip

Appointment Phone:

(     )

FAX#: (    )

Email Address

Type of Professional

Check all that apply

 Physicians:

Pediatrician   

Pediatric General Surgeon

Family Practitioner

Adult General Surgeon

Internal Medicine physician 

Surgeon who cares for both

Endocrinologist  Adult 

Orthopedist 

Pediatric Endocrinologist 

Ear, Nose and Throat 

Endocrinologist who cares for both  

Pediatric Pulmonologist / Lung Specialist

Pediatric Psychiatrist 

Adult Pulmonologist / Lung Special

Adult Psychiatrist

Pulmonologist / Lung Special who sees both

Psychiatrist who cares for both

Pediatric Ophthalmologist

Geneticist 

Adult Ophthalmologist

Gastroenterologist (stomach specialist)

Ophthalmologist who sees both

Neurologist

Podiatrist

Other

Psychologist/Counselor

Dietician

Dentist – Orthodontist

Other

Explain: 

Is the professional associated with a clinic or hospital? If yes- please indicate.

  ---- No Yes

Does this professional speak languages other than English? If yes – which ones?

Comments:

Person Completing form:

Date Information Obtained

Date Information Confirmed (PWSA staff only)