For Physicians
Patient Portal
PHYSICIAN REFERRAL
ESPAÑOL
Home
Providers
About
Office & Policies
Procedures
FIBROSCAN
ERCP
UPPER ENDOSCOPY
BOWEL CAPSULE ENDOSCOPY
HEMORRHOID BANDING
SMART PILL MOTILITY TESTING
COLONOSCOPY
PEG TUBE PLACEMENT
H. PYLORI BREATHING TEST
Patient Education
Diseases & Symptoms
Educational Information
Diet Recommendations
For Physicians
Forms
Contact
Physician Referral Form
PHYSICIAN INFORMATION
Physician's Full Name
*
Physician’s Phone
*
Physician’s Fax
TYPE OF APPOINTMENT
Type of Appointment
*
Consultation
Colonoscopy
Hemorrhoid Removal
Other
Providers
Reason for contact
*
Dr. Elsa S. Canales M.D.
Dr. Alfredo Camero Jr. M.D.
PATIENT INFORMATION
Full Name
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Female
Male
Home Phone
*
Work Phone
*
Alternate Phone
REASON FOR REFERRAL
REASON FOR REFERRAL
Bowel Capsule
Colonoscopy Screening
Consultation
Fibroscan
Hemorrhoid Banding
H. Pylori Breath Test
Comments/Notes
You may fax us medical records or information about your patient to: (956) 795-4779, or e-mail us at : scheduling@gastrolaredo.com
