[Street address], [City, State ZIP]
Referrals: Tel [phone] · Fax [fax]
Specialist Referral
Provisional - results pending
SAMPLE / SIMULATED - demonstration only, not a valid referral.
Sample Patient
60 / F
[MM/DD/YYYY]
[MRN]
10/12/2026
[Payer] / [Auth #]
Refer to
Dr. Johnson, Gynecology (incontinence / urogynecology)
Also: Dr. Smith, Gynecology (breast cancer), consult if hormone therapy is considered.
Also: Genetic counseling / cancer genetics (not on panel list).
Reason for referral
Persistent menopausal hot flashes and night sweats for 5 years (onset at menopause, age 55) with
urinary urgency, suspected genitourinary syndrome of menopause. Requesting evaluation and management
options. Mother had breast cancer at age 40, which bears on any hormone therapy decision.
Diagnoses
N95.1 - Menopausal and female climacteric states (ICD-11 GA30.4)
R39.15 - Urgency of urination
R61 - Generalized hyperhidrosis (night sweats)
Z80.3 - Family history of malignant neoplasm of breast