DOCTOR REFERRAL FORM

Referral # 28433 Date 27/03/2024

SPECIALTY: PODIATRY

Dr Hillel Gluch TEL: 02-624-9004

Hadar Mall, 26 pierre koen FAX:
JERUSALEM hillel@hillelgluch.com

I am referring Rachel Silverman Member ID 658398

to you for consultation because
Ingrown toenail

I would greatly appreciate your evaluation, treatment and / or

recomendations. Please briefly fill in the lines below and return the referral

Referring Physician DOC Referral

Send Bill: By fax: (02)651-5029

By E-Mail: info@aim.co.il
By Mail: AIM 8 Admor M’Boyan Jerusalem 95403

To be filled by specialist
Diagnosis

Test Requested

Treatments and Recommendations

Date: ___/___/______
Specialist Signature
Good for only one visit. If further visits are necessary, additional referral forms are mandatory