To: Arthritis & Osteoporosis Clinic

Dr. Eugene Fung, Rheumatologist

Fax 254-755-4585

From:

Priority Rheumatology Appointment Request

Patient:

Phone:

Date of Birth:

Consulting Problem:

Please circle the following that apply:

1. Inflammatory arthritis associates with significantly elevated

   ESR or CRP,
   Rheumatoid factor
   ANA
   HLA-B27

2. Arthritis that is accompanied by

   psoriasis,
   inflammatory bowel disease,
   ocular,
   muco-cutaneous,
   genitourinary lesion
   or constitutional symptoms or signs such as fever and weight loss

If possible fax copy of abnormal lab results and other applicable information with this request.

Fax to 254-755-4585

*This request form can be downloaded from our website
www.arthritisresearch.com