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For consult requests requiring a patient to be seen in less than 3 days, please call 1-800-GO-MERCY (1-800-466-3729) and ask for an urgent appointment. For scheduling questions or questions regarding this form please call 816-234-3700.

Referral Information
Specialty Reasons for Consultation Patient Symptoms Action
Weight Management
Referring Provider
Primary Care Provider
Patient Information
Parent/Guardian Information
Insurance Information
Signature