Hand Trauma And Surgery Specialists

Patient Intake Consult Form

Please fill out the following fields in each tab as completely as possible to ensure the most effective consult. DO NOT include any patient protected health information (PHI).

select any/all that apply

If patient has any relevant x-rays, please upload them.
Accepted formats: .jpg, .jpeg, .gif, .png, .webp,.pdf format.

Use this area for any optional/additional images uploaded to chart

Select any/all that apply

Please ensure that patient PHI has not been included in the form submission.

For Inpatient Consults and Outpatient Follow-ups, please fax the facesheet to (470) 305-1110 or send the facesheet as a direct message to Dr. Mangonon in Epic. If a patient is being referred for Outpatient Follow-up, please share the following website information with the patient – www.handtraumaandsurgery.com – which contains the office phone number and a link for online appointment scheduling.

You selected a phone consult, please contact Dr. Mangonon directly after form submission at (470)305-1581