St. Elizabeth'sServices and Clinical CentersUrology

Urology Consult Request Form

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 Male Female
Biopsy Gleason Score
Date of Biopsy
How many cores taken?
How many cores positive?
Previous Abdominal Surgery
Other Medical Problems Stroke
MI / Heart Failure
Renal Failure
If Other, please specify   
Your Health Insurance*
*  Pain
If Other, please specify  
How did you find out about us?
(check all that apply)

Referred by Primary Care Physician 
Referred by Urology
Referred by friend / family
If referred by friend / family, please specify:  

Existing Steward® Health System patient
Know former patient
Saw advertisement
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Internet search
If Other, please specify  

Additional information  

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