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Request for consult

Request for consult with sub-specialist 

This form is to request a consult with one of our specialists (discuss a treatment plan, ask for advice, determine if care can be managed in the pediatrician’s office vs a referral, etc.) Please click here if you need to refer a patient or click here to schedule an appointment.

If this an urgent request (within one hour) please call your CHoR contact:

Karol Wilson
Central and Eastern Virginia
Phone: 804.239.3819

Lexi Aman
Northern and Central Virginia
Phone: 804.229.9351

Level of response from provider requested Requesting provider name  *Requesting provider email

This is for confirmation email only 
 *
Practice name  *Contact number at practice Cell phone of provider for after hours  *Best time to contact  *Alternative contact person within practice Alternative contact number 

Patient information

Patient full legal name: Date of birth (MM/DD/YYYY) Service requested Has this sub-specialty seen this patient previously? Brief description of issue Provider preference (availability dependent upon requested turnaround time) Name of person submitting request  *