MENU Request Appointment Locations Click here to review our COVID-19 protocols REFER A PATIENT YOUR INFORMATION Referring Clinic * Name of Person Initiating Referral * Phone * Referring Physician * Return Fax # * Email (optional) YOUR OFFICE IS REQUESTING THE CONSULTING OPINION OF IOWA ORTHO REGARDING: Patient Name * Patient DOB * Patient Primary Phone * Patient Secondary Phone * Patient Email (optional) Will never be used for marketing or solicitation purposes Reason to be seen * Is the Patient their own Medical Decision Maker? * Yes No Will an Interpreter be Needed for Patient? * Yes No PATIENT INSURANCE INFORMATION Billed to * Private Insurance Other: Work Comp Self Pay Name of Insurance (optional) Authorization Number (optional) Address of Claims (optional) Subscriber Name * Subscriber Date of Birth * Policy Number * Group Number SUPPORTING DOCUMENTS Clinic Notes Clinic notes are required for a referral. Please upload clinic notes here, or fax to 515-248-8888. To upload multiple documents hold the Ctrl key while selecting documents. Bone Scan Lab Tests MRI X-rays Medication List CT EMG PT Additional Documents If the patient has had any of the following procedures for the diagnosis listed above, please check box. Each supporting document should be uploaded to this form or be faxed to 515-248-8888. SECOND OPINIONS Has the patient ever seen an Orthopaedic, PM&R or Pain Physician for this problem? Yes No Physician Name Dates Has the patient ever had surgery on this body part? Yes No If yes, is there any hardware? Is this work related? Yes No special or additional notes about this patient A representative will contact the patient and your office with in 1 business day to schedule/convey an appointment time for the patient. Please wait... Call or text: 515-247-8400 Monday–Friday 8:00am to 5:00pm Copyright© 2018 Iowa Ortho All Rights Reserved. SERVICES IOWA ORTHO BLOG LOCATIONS FOR PATIENTS ABOUT CAREERS OUR PROVIDERS CONTACT US TERMS & CONDITIONS PATIENT PRIVACY & NON-DISCRIMINATION STATEMENT Website By Happy Medium