Dear Referring Physician:
Patient's name: __________________________________________________.
Your patient has indicated an interest in a Virtual Second Opinion at my Thyroid.com Santa Monica Thyroid Diagnostic Center website. The patient will not receive a consultation directly from me, as my second opinions are provided by mail. You can agree to refer your patient, and we will report to you in writing. If you agree to your patient's request for a second opinion, you may submit your patient's history and related materials by mail. After receiving a complete medical history, patient's payment and related materials, my opinion will be mailed to you.
Please note, payment for services is the responsibility of your patient and is unlikely to be covered by his or her insurance.
If you agree to refer you patient, as he or she has requested that we obtain your approval, please sign below and mail or fax to us at:
Santa Monica Thyroid Diagnostic Center, 1328 - 16th Street, Santa Monica, CA 90404. Fax number: 310-395-8147.
Physician Name: __________________________________________________
Physician's Signature: ______________________________________________
Date: ___________________________________________________________
If you have any questions, call us at: 1-800-408-4909
Very truly yours,
Richard B. Guttler, M.D., F.A.C.E.
Director of Santa Monica Thyroid Diagnostic Center
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