Patient Referral Form Please fill out the details in the form below to submit a new appointment request for Central Texas Surgical Associates DISCLAIMER: If you are experiencing a medical emergency, please call 9-1-1. This form is for appointment requests only. Referring provider name (if applicable) Reason for appointment —Please choose an option—AbscessesAppendicitisBariatricColon TumorsDiverticulitisGallbladderGERDHerniasLipomasMelanomaPeptic Ulcer DiseaseSkin LesionsSmall Bowel ObstructionTumors or Cysts Additional Details Urgency —Please choose an option—EmergentRoutineUrgent First name Middle name Last name Suffix Date of birth Gender —Please choose an option—MaleFemale Street address Zip code City State —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Email Phone number Phone type HomeMobileWork Insurance company —Please choose an option—No insuranceNot listedAETNABlue Cross Blue ShieldCIGNAFirst HealthGEHAGolden RuleHumanaMedicarePrivate Health Care System Network (PHCS)The MultiPlan NetworkPrivate Health Care System Network (PHCS)TriCareUnited Healthcare Policy ID Number Policy Group Number Is the patient the insurance holder? YesNo Is an insurance referral required? YesNo Preferred location —Please choose an option—Any, first availableRound RockMcKinneyFlower Mound Provider to see —Please choose an option—Any, first availableAndy L Hawthorne, MDBratcher L Runyan, MDMario A Longoria, MDWade W. Dunlap, MDJames P. Carroll, MDChad E. Treece, MDColin L. Doyle, MD Preferred day of week —Please choose an option—Any, first availableMondayTuesdayWednesdayThursdayFriday Preferred time of day —Please choose an option—Any, first availableMorningAfternoon