Physician Referral

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Referring Physician’s Offices may complete the following form to refer a patient to our office via the web. If the appointment is of an urgent nature, please call our office to make the appointment at 231-627-4364. After filling out all pertinent information, click <submit> at the bottom of the form. The patient’s information will be directed to our receptionist. She will call your office with the patient’s appointment date and time.

If you prefer to fax the information to our office, please click this FORM LINK to open and print the Physician Referral form. Don’t forget to fax the referral information to 231-627-7758.

* = Required Field
* Referring Physician Name:
* Referring Physician - Staff Member making referral:
Has the patient had x-rays at other places than Cheboygan Memorial Hospital?		Yes No
* Patient First Name:
* Patient Middle Initial:
* Patient Last Name:
* Patient Home Phone:
Patient Work Phone:
* Sex:
* Birth Date:
* Soc Sec #:
* Mailing Address:
* City:
Requested Surgeon:		Dr. Burandt Dr. Duncan Dr. Miller
Reason for referral:
Has this patient or any of their relatives been seen here before?		Yes
if so, who?
* State:		* Zip:
* Payment Method:
** = Required Field if selecting Insurance as payment method.
Primary Insurance Type
** Insurance Type:
** Subscriber’s Name (whose name is the insurance under):
** Subscriber’s Birthdate if different than patient:
** Subscriber’s SS# if different than patient:
** Insurance Contract #:
** Insurance Group #:
Secondary Insurance Type
Insurance Type:
Subscriber’s Name (whose name is the insurance under):
Subscriber’s Birthdate if different than patient:
Subscriber’s SS# if different than patient:
Insurance Contract #:
Insurance Group #:
Tertiary Insurance Type
Insurance Type:
Subscriber’s Name (whose name is the insurance under):
Subscriber’s Birthdate if different than patient:
Subscriber’s SS# if different than patient:
Insurance Contract #:
Insurance Group #: