Please fax the following to PATIENT REFERRAL FORM Please fax the following to 512-459-1399 Labs: Basic Chemistry, Urinalysis, 24 hour urine results from the past year. Imaging: any ultrasound or CT studies related to renal evaluation Medical Information: a) Medication List b) Problem List c) Last 2 office Notes Ashvin Baru, M.D. Judith Betts, MD Cristian Cipleu, MD Raymonda El Khoury, MD Amsalu Erko, MD Peter Hines, MD Timothy Hines, MD Ting Chi Lu, MD Krzysztof Lyson, MD Ravi Mididoddi, MD Peter Miller, MD Scott Moore, MD Paul Nader, MD Yasser Nasser, MD Annalisa Perez, MD William Rodriguez, MD Mark Rosen, MD Nicholas Rowder, MD Edith Simmons, MD Sujatha Venkatesh, MD Malavika Vinta, MD Byron Welch, MD Urgency: ∆ High ∆ Normal ∆ Patient will call Reason for Referral ∆ Increased Creatinine level ∆ Low eGFR ∆ Chronic Kidney Disease ∆ Proteinuria ∆ Hematuria ∆ Abnormal electrolytes ∆ Hypertension ∆ Edema ∆ Glomerulonephritis ∆ Other Please circle preferred location: North Locations: Central Locations: South Locations: North Office: The Arbors at Creek’s Edge 4100 Duval Rd., Bldg. IV, Ste. 102 Austin, TX 78759 West Central Office: 408 W 45th Street Austin, TX 78751 East Central Office: 3000 N IH-35, Ste. 635 Austin, TX 78705 South Office: 321 W Ben White Blvd, Ste. 205 Austin, TX 78704 Kyle Office: 134 Elmhurst Drive Kyle, TX 78640 Bastrop Office: 441 Hwy 71, Ste. H Bastrop, TX 78602 Cedar Park Office: 1720 E Whitestone Blvd, Ste. A Cedar Park, TX 78613 Round Rock Office: (Behind Round Rock Medical Center) 16010 Park Valley Dr., Ste. 100 Round Rock, TX 78681 For an appointment, please call 512.451.5800 Georgetown Office: Austin Avenue Medical Plaza 3201 South Austin Ave, Ste. 325 Georgetown, TX 78626