180 Medical E-Script Referrals Portal

Facility

Company / Practice Name *

Practice EMR System

Address Line 1 *

Address Line 2

City *

State *

Postal Code *

Phone *

Fax *

Field Consultant

Urological Division

Patient First Name *

Patient Last Name *

Patient Phone *

DOB *

Age

Urological Supplies

Product Type *

FR / Intermittent Size

Tip Type

Individual Lube Packets

External Size

Foley Size

Balloon

Tip and Material Type

Product Details (HCPC, Name, and/or Description) *

Quantity *

90 Day Supply

Number of Refills

Order Comments

Referrer / Physician Information

Physician First Name (Uppercase enforced) *

Physician Last Name (Uppercase enforced) *

Nurse / M.A. Name*

Date

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