Referral forms for our Lawrence County and Mason County facilities and the Health
and Rehabilitation Center in South Charleston are now available. The forms are available
in Microsoft Word and Adobe Acrobat format. Please choose from the List below.
Instructions After downloading the appropriate form, you can e-mail a
completed copy of the form for Lawrence County. You will need to e-mail both Tammy Duffield
(tduffield@holzerclinic.com) and Erika Bing(ebing@holzerclinic.com). Referral forms
for Holzer Clinic of West Virginia or the Health and Rehabilitation Center should be faxed
to the appropriate number. You can also fax the Lawrence County referral forms using the
appropriate number below. You may also call (740) 886-9403 for more details or instructions
for the Lawrence County forms.
|
Holzer Clinic of Lawrence County |
|
Allergy
Christopher Clark, MD
Phone: (740) 886-9403
Fax: (740) 886-3053
MS Word and
Adobe
|
Gastroenterology (GI)
Mark A. Subik, MD
Phone: (740) 886-9403
Fax: (740) 886-3053
MS Word and
Adobe
|
General Surgery
Alice Dachowski, MD
Phone: (740) 886-9403
Fax: (740) 886-3053
MS Word and
Adobe |
Orthopedics
Wayne Amendt, MD
Phone: (740) 886-9403
Fax: (740) 886-3038
MS Word and
Adobe |
Physical Medicine & Rehabilitation
Glen P.Imlay, MD
Phone: (740) 886-9403
Fax: (740) 886-3038
MS Word and Adobe
EMG ONLY forms:
MS Word and Adobe |
Podiatry
Jeffrey E. Shook, DPM, PLLC
Phone: (740) 886-3003
Fax: (740) 886-3038
MS Word and Adobe |
Rheumatology
Mehmoodur Rasheed, MD
Phone: (740) 886-9403
Fax: (740) 886-3053
MS Word and Adobe |
|
|
| Mason County Facilities |
Holzer Clinic of West Virginia
Dr. Lois Bosley,
Dr. Michael Zirille, or
Dr. Murray Willock
Phone: 304-675-4498
Fax: 304-675-6569
MS Word and Adobe |
|
|
| Health and Rehabilitation Center (South Charleston) |
Phyical Medicine and Rehabilitation
EMG Referral
Dr. Babayev or
Dr. Chandra
Phone: 304-746-3700
Fax: 304-744-2602
MS Word and Adobe |
Phyical Medicine and Rehabilitation
Dr. Babayev or
Dr. Chandra
Phone: 304-746-3700
Fax: 304-744-2602
MS Word and Adobe |
|
| Sleep Lab |
Sleep Evaluation Direct Referral History and Physical Form
Phone: 866-28-SLEEP (75337)
Fax: 740-446-1298
MS Word and Adobe |
©2008 Holzer Clinic