To Obtain a Doctor Referral

Please print out the following form (pdf version)

and mail to the LDF.

Dear Patient:

   The LDF encourages you to work with your primary caregiver regarding your own vector-borne disease case. This is the best person to deliver your medical care because Lyme disease and other vector-borne diseases can affect your whole body, not just an isolated part. Also, your family doctor is the person who can deliver healthcare at the lowest possible cost and minimal travel.

   However, if you want a referral to a consulting physician to work with your doctor or referral to another doctor for a second opinion, please: 1. complete the following information, 2. attach a $10 processing fee, 3. include a Self-Addressed Stamped Business size envelope, and 4. mail to the above address. 

1. Your Name _________________________________  Daytime Phone _________________

   Address ___________________________________

   City ______________________________________    State ________   Zip ____________ 

2. Where are you located in the State? Required. Check only one.  ___North   ___Central   ___South.    

                                                               Alternative: ___East   ___West.

3. I need a doctor for:  (chose one)  ___ Child  ___ Adult    Are you pregnant? ____ (Yes / No).

4. I am willing to see a doctor who uses alternative/complimentary medicine.  _____ (Yes/No).

5. I think I have the following vector-borne disorder(s) __________________________________.

6. My symptoms include: [check the aea(s) that represents your worst problems]  

___ General illness - rash, profound fatigue, flu-like symptoms, fever, nausea, & vomiting.

___ Neurological - loss of reflexes, radiating abnormal sensations, meningitis, extreme headaches, alteration in smell or taste, difficulty chewing/swallowing/speaking, facial droop (Bell's palsy), abnormal brain tests (MRI, EEG), cognitive or behavioral changes.

___ Eye problems - vision changes, reduced vision/blindness, retinal damage, conjunctivitis, inflammation, lazy eye or light sensitivity.

___ Joint problems - pain (temporary or chronic, usually not symmetrical), swelling, TMJ-like pain.

___ Heart problems - irregular heartbeats, heart block - sometimes requiring a pacemaker.

___ Blood abnormalities – decreased in red blood cells, increase in white blood cells.

___ Night sweats.  

   The $10 processing fee is the only support for the cost of maintaining the referral program. The LDF does not receive funding for physician referrals except for this fee.

   Every doctor has different opinions about: diagnosis and treatment of vector-borne diseases, price for the initial and follow-up visit, insurance coverage, waiting time for an appointment, and terms for working with the patient. You should clarify these conditions with the doctor's office before you see the doctor. Most physicians on our referral list are pleased to work with your physician in order to save you the time and expense of a special visit. If we don't have a physician near you, we will send you the name of the closest listed physician who may be the best choice for your circumstances. We make no representation that we have a physician in your state.   

   I assert that I am sick and that I am submitting this referral for my own medical care. The LDF reserves the right to return your fee without a physician referral for any reason we deem appropriate.  I understand that the LDF does not accept email, fax, nor phone requests.  The LDF does not  provide repeated nor multiple referrals.

______________________       ______

            

Your Signature

Date    ©LDF 2009