Please fill out and submit the form below. Fax patient records to:

520-229-9107, attn: Medical Records

You may also e-mail patient records and referrals to:

patientforms@pimalung.com.

 

Please check all appointment types that apply to this patient.

Patient Information

Patient Name:* 

 

Date of Birth:* 

 

Home Phone:* 

 

Mobile Phone: 

 

Work Phone: 

 

Street Address: 

 

City: 

 

State: 

 

Zip Code: 

 

Primary Insurance:* 

 

Secondary Insurance: 

 

Tertiary Insurance: 

 

Social Security #: 

 

Referring Provider:* 

 

Referring Office Phone:* 

 

Referring Office Fax: 

 

Comments: 

Clinic Appointments

Appointment Requested (please choose):

 

Diagnosis: 

Sleep Study (PSG)

Pocedure Requested:

 

Diagnosis: 

Pulmonary Function TEsting (PFT)

Procedure Requested:

 

Diagnosis: 

Echocardiography (ECHO)

Procedure Requested:

 

Diagnosis (please choose):

Vascular Lab

Procedure(s) Requested (please choose):

 

Diagnosis: 

 


Please send referral if needed.

 

*required information