1. Please fax the following to
PATIENT REFERRAL FORM
Please fax the following to
Labs: Basic Chemistry, Urinalysis, 24 hour urine results from the past year.
Imaging: any ultrasound or CT studies related to renal evaluation
Medical Information:
a) Medication List
b) Problem List
c) Last 2 office Notes
Ashvin Baru, M.D.
Judith Betts, MD
Cristian Cipleu, MD
Raymonda El Khoury, MD
Amsalu Erko, MD
Peter Hines, MD
Timothy Hines, MD
Ting Chi Lu, MD
Krzysztof Lyson, MD
Ravi Mididoddi, MD
Peter Miller, MD
Scott Moore, MD
Paul Nader, MD
Yasser Nasser, MD
Annalisa Perez, MD
William Rodriguez, MD
Mark Rosen, MD
Nicholas Rowder, MD
Edith Simmons, MD
Sujatha Venkatesh, MD
Malavika Vinta, MD
Byron Welch, MD
Urgency:
∆ High ∆ Normal ∆ Patient will call
Reason for Referral
∆ Increased Creatinine level ∆ Low eGFR
∆ Chronic Kidney Disease ∆ Proteinuria
∆ Hematuria ∆ Abnormal electrolytes
∆ Hypertension ∆ Edema
∆ Glomerulonephritis ∆ Other
Please circle preferred location:
North Locations:
Central Locations:
South Locations:
North Office:
The Arbors at Creek’s Edge
4100 Duval Rd., Bldg. IV, Ste. 102
Austin, TX 78759
West Central Office: 408 W 45th Street
Austin, TX 78751
East Central Office:
3000 N IH-35, Ste. 635
Austin, TX
South Office:
321 W Ben White Blvd, Ste. 205
Austin, TX 78704
Kyle Office:
134 Elmhurst Drive
Kyle, TX 78640
Bastrop Office:
441 Hwy 71, Ste. H
Bastrop, TX
Cedar Park Office:
1720 E Whitestone Blvd, Ste. A Cedar Park, TX 78613
Round Rock Office:
(Behind Round Rock Medical Center) Park Valley Dr., Ste. 100 Round Rock, TX 78681
For an appointment,
please call
Georgetown Office: Austin Avenue Medical Plaza
3201 South Austin Ave, Ste. 325
Georgetown, TX 78626