Patient Appointment (Physician Request)

To schedule an appointment for your patient with CornerStone Ear, Nose, & Throat, please complete sections 1, 2 & 3 and then click submit. We will schedule the appointment then email or fax tracking information back to you for your records.

Please note that some of the fields of this form are required (*). Please complete the required fields before submitting.

Referring Provider Information * Referring Practice * Referring Physician * NPI# * Phone Number Fax Number

Date of Request

* Month * Day * Year * Referral Coordinator * Preferred Physcian * Preferred Location

Start Date

* Month * Day * Year

End Date

* Month * Day * Year

Patient Information * Patient Status * Patient First Name * Patient Middle Name or Initial * Patient Last Name

Date of Birth

* Month * Day * Year Social Security Number Parent or Guardian Name (if applicable) Patient Contact Email * Patient Contact Telephone Preferred Contact Method * Diagnosis / Complaint

Insurance Information Insurance Company Member / Recipient ID# Referral / Carolina Access # Number of Visits

Healthcare Facilities and Privileges

All of the physicians at Cornerstone Ear, Nose & Throat are Board Certified in Otolaryngology and maintain medical, surgical and/or admitting staff privileges at the following Carolinas Healthcare System, Presbyterian/Novant, and independently owned facilities:

CMC Union, Monroe, NC

CMC Pineville, Pineville, NC

Matthews Presbyterian Hospital, Matthews, NC

Union West Ambulatory Surgical Center, Indian Trail, NC

The Surgery Center at Edgewater, Indian Land, SC

Presbyterian Surgery Center Ballantyne, Presbyterian Medical Plaza, Charlotte, NC

Presbyterian Surgery Center Monroe, Presbyterian Medical Plaza, Monroe, NC.

Arboretum

Monroe

Union County

Patient Appointment (Physician Request)

Questionaires

Privacy

Pre and Post-Operative Instructions

Healthcare Facilities and Privileges