Provider Referral for GI Appointment

For your convenience, please complete this online form. This is to help us better serve you and your patient. We will contact the patient and fax the appointment information to you with the date/time within 24 business hours. For questions/concerns, contact us at 706-548-0058. Thank you for your referral!

Patient Request for GI Appointment

Referring Physician Information

Patient General Information

Please be sure to fax any medical records pertaining to the reason for visit, such as:

Last office note, recent lab results, GI Radiology, Endoscopy Reports, GI Pathology Reports, and patient’s insurance card to 706-548-0555.

Insurance Information

If patient’s insurance requires a referral authorization, please fax the authorization # to 706-548-0555. This referral will need to have an authorization number from the insurance company.

Medical Information

To submit medical records with this referral, please upload the documents here.

NOTE TO REFERRING OFFICE: Please be sure to fax any medical records pertaining to the reason for visit, such as:

  • Last office note
  • Recent lab results
  • GI X-Rays
  • Endoscopy/GI Pathology Reports
  • Copy of Insurance card(s)

NOTE TO PATIENT: Your initial office visit will be a clinic consultation prior to scheduling any tests or procedures. You will not need to fast and will not be required to bring a driver for the clinic consultation visit. 


Please arrive 15 minutes early for your appointment and bring:

  • Picture ID (government issued)
  • Insurance card(s) (all active insurance)
  • Co-pay/co-insurance
  • List of medications

Patient Request for GI Appointment

Referring Physician Information

Patient General Information

Please be sure to fax any medical records pertaining to the reason for visit, such as:

Last office note, recent lab results, GI Radiology, Endoscopy Reports, GI Pathology Reports, and patient’s insurance card to 706-548-0555.

Insurance Information

If patient’s insurance requires a referral authorization, please fax the authorization # to 706-548-0555. This referral will need to have an authorization number from the insurance company.

Medical Information

To submit medical records with this referral, please upload the documents here.

NOTE TO REFERRING OFFICE: Please be sure to fax any medical records pertaining to the reason for visit, such as:

  • Last office note
  • Recent lab results
  • GI X-Rays
  • Endoscopy/GI Pathology Reports
  • Copy of Insurance card(s)

NOTE TO PATIENT: Your initial office visit will be a clinic consultation prior to scheduling any tests or procedures. You will not need to fast and will not be required to bring a driver for the clinic consultation visit. 


Please arrive 15 minutes early for your appointment and bring:

  • Picture ID (government issued)
  • Insurance card(s) (all active insurance)
  • Co-pay/co-insurance
  • List of medications

We will call the patient to give them their appointment information.


THANK YOU AGAIN FOR YOUR REFERRAL!