MD Referrals

1. INJURY INFORMATION

Diagnosis: *

Have x-rays and/or an MRI been taken for this condition? *If yes, please have patient bring with them to the appointment. *

Yes No

2. PATIENT INFORMATION

Patient Name *

First Name Last Name

Date of Birth *

Date

Home Number *

Area Code Phone Number

Cell Phone *

Area Code Phone Number

Number *

Insurance *

3. APPOINTMENT INFORMATION

First Available

Yes

Please note that although physicians are listed below by specialty, all AOC physicians perform general orthopaedic services.

Foot and Ankle

John C. McAndrew, III, MD Grant M. Shell, MD

Hand

Jared L. Burkett, MD William A. Crotwell, III, MD Suanne White-Spunner, MD

Spine Care

D. Kevin Donahoe, MD Tim S. Revels, MD

Joint Replacement

Matt Barber, MD Michael L. Granberry, MD J. Grant Zarzour, MD

Sports

Clayton G. Lane, MD W. Christopher Patton, MD Cesar M. Roca, Jr., MD

General Orthopaedics

Andre J. Fontana, MD Russell A. Hudgens, MD Roger M. Setzler, MD

Preferred Appointment Day: *

No Preference Monday Tuesday Wednesday Thursday Friday

Preferred Appointment Time: *

No Preference AM PM

Referring Physician: *

Clinic: *

Contact Person: *

Email *

example@example.com

Phone Number *

Area Code Phone Number

Fax Number *

Area Code Phone Number

We will call your patient to schedule their appointment. You will receive confirmation once their appointment has been scheduled. Please feel free to call our PHYSICIAN REFERRAL LINE (251.410.3807) with any questions you may have. Thank you for referring your patients to Alabama Orthopaedic Clinic, P.C.