For Referring Physicians

Please fax the following documents to (585) 341-8453 prior to the patient's visit. Each sheet should be labeled with the patient’s name and date of birth.

• Contact telephone number/pager for your office – it is important that our providers be able to contact you for consultation if any medical needs for your patients arise while they are under our care.
• Copy of patient’s demographics.
• Most recent Clinical Summary – within 30 days.
• Most recent Clinical Summary within 60 days for nursing home patients.
• Most recent Laboratory results – within last 7 days.
• Physician’s order form signed and dated by physician/nurse practitioner/physician assistant, including any additional medication orders needed to care for your patient during their stay.
• Current medication list.
• Consent for blood transfusion signed and dated by MD/NP/PA , and patient or patient guardian. If phone consent is completed with patient, please write “phone consent obtained” on consent form underneath patient’s signature line.

Forms

• Blood Transfusion Physician Check List
• Blood Transfusion Referral Process
• Patient Care Orders - For Blood Transfusion
• Patient Care Orders - Blank Form
• Patient Consent Form
• History and Physical Form