Referring Dr Portal

For referring physicians only.

Referring Physicians, please take a moment to fill out this form for your patient indicating their reason for visit and their contact information. We will get in touch with them right away to schedule an appointment.

[contact-form to=’DLaRocca@lakeside-ent.com’ subject=’Referral from Referring Physican Portal’][contact-field label=’Patient Name’ type=’name’ required=’1’/][contact-field label=’Patient Email’ type=’email’ required=’1’/][contact-field label=’Patient Date of Birth’ type=’text’ required=’1’/][contact-field label=’Patient Address’ type=’text’/][contact-field label=’Patient Home Phone’ type=’text’ required=’1’/][contact-field label=’Referring Physician Name’ type=’text’ required=’1’/][contact-field label=’Select an ENT Physician’ type=’select’ options=’Dr. Eric Birken,Dr. Srinivas R. Kaza,Dr. Jay Yates,Dr. Roger Sequeira,Dr. Susan L. Fulmer’/][contact-field label=’Select Location’ type=’select’ options=’Canandaigua Office,Clifton Springs Office,Batavia Office’/][contact-field label=’Reason for visit’ type=’textarea’ required=’1’/][/contact-form]