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Referral Extension Request
909-594-3382
Referral Extension Request
Fairway Children's Medical Group,2707 East Valley Boulevard, Suite 215, West Covina California
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Pay My Bill
Referral Extension Request
909-594-3382
Referral Extension Request
Patient Portal
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Are you a new or returning patient?*
New
Returning
Child’s First Name*
Child’s Last Name*
Date of Birth*
Sex*
Male
Female
Other
Reason
Well Checkup
Sports Pre-participation Exam
Sick Visit
Need Referral
Appointment Change needed
Other questions
Lab result question
Primary Caregiver Name*
Primary Caregiver Phone*
Primary Caregiver Email*
Secondary Caregiver Name
Secondary Caregiver Phone
Email*
Phone*
Preferred Language
English
Mandarin
Cantonese
Spanish
I have read and agreed to the
Privacy Policy
and
Terms of Use
and I am at least 13 and have the authority to make this appointment.
I agree to receive text messages from this practice and understand that message frequency and data rates may apply..
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Patient Portal
Referral Extension Request
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Referral Extension Request
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Referral Extension Request
To request an extension to your prior authorization, please complete the information below
Patient Information
This information will be sent to your provider and will be kept as part of your patient records.
First Name*
Last Name*
Email Address*
Mobile phone number*
Date of Birth
Specialty*
Specialist's Name*
Specialist's Phone Number*
Date of your appointment scheduled with specialist*
Please review to ensure the details are correct before completion.
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Referral Extension Request
