Michelle Thomas, MD FACS

A practice of general surgery in Anchorage since 1997

REFERRING PROVIDERS:

Dr. Thomas’ office would be happy to take your patient referral. Just enter the information below, and we’ll take care of the rest. We’ll contact the patient, handle the problem, and keep you informed of your patient’s progress.

Alternatively, you can call the office at 907-644-1033 or fax us the information at 907-644-0764.

Physican Referral

Patient's Name*
First Last
Phone*
Patient's Date of Birth*
Diagnosis or Problem*
Brief Clinical Note*
Referring Provider*
First Last Suffix
Please e-mail Referring Provider a Copy of this Referral
- Yes
- No
Referring Provider's Website

(optional)
Please contact referring physican by:*
- fax report to my office
- phone
- forwarding clinical note by mail
- e-mail
Check all that apply. The default assumption will be to fax report to referring provider's office.
Referring Provider's Phone
Referring Provider's e-mail
Referring Provider's Address
Street Address Address Line 2 City State ZIP Code
Referring Provider's Fax