Referral Form

Desert Medical Advances
69730 Hwy 111, Suite 101
Rancho Mirage, CA
760-341-6800

Referral Form
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Desert Medical Advances is associated with Advances in Medicine and together we offer new treatments for several diseases, free of charge. All programs have been reviewed by the FDA. The medications are being evaluated for significant advances either treating illness better or safer. All patients participating in these programs can stop at any time.

For more information call: 760-341-6800

Print out this form, fill it in and either mail it, drop it off at the office or fax it to 760-341-9872.

Name:______________________________________________

Phone:_____________________________

Address:__________________________________________

City:_________________________ State:____________ ZIP:_______________

List medications you are presently taking: _____________________________________________________________

________________________________________________________________

Do you have asthma? Y   N
Hay fever? Y   N
Lung disease Y   N
Have you smoked less than 10 years? Y   N
Have you smoked more than 10 years? Y   N
Do you have high cholesterol? Y   N

If female, please answer the following:
Have you had a hysterectomy? Y   N
Date of menopause (last period) _________
Do you use estrogen or Evista now? Y   N
Have you had breast cancer? Y   N
Do you have hot flashes now? Y   N

Note: FDA generally excludes anyone who is pregnant, had cancer in the past 5 years (but squamous or basil skin cancers are not excluded), or has significant renal or liver dysfunction such as over two times normal lab values. Current estrogen use would preclude a new estrogen program. Call if you are on coumadin or steroids.

Person sending this form:_________________________________________________