Request for Consultation Form

FIRST BOX TO BE FILLED OUT BY SCHEDULER AND FORWARDED TO
KATE HOWELL
Patient Name
MRN
DOB
Patient Phone
Outside Films (Y/N)     

If Yes, then Where, When, What:
Exam Requested
Diagnosis
Scheduler Scheduler notifying K. Howell
Insurance
Authorization
Physician
Physician's Phone
   

SECOND BOX TO BE FILLED OUT BY KATE HOWELL.
SHE WILL EVALUATE FILMS WITH RADIOLOGIST
Imaging Studies Performed
Level of Interest
Radiologist that checked films
Consult (Y/N)
Special Requests by PT (Specific dates, Physician, etc.)
Pre-Op  (Y/N)
If Yes, return to scheduling for Pre-Op Appointment
   

THIRD BOX TO BE FILLED OUT BY KATE HOWELL
Imaging Studies Needed
Date/Time Scheduled
Allergies
Medications
Area of Pain
History of Cancer
Type:
When:		 (Y/N) 

Treatment for Cancer
Surgical History
Additional Information
Significant Past Medical History
Consultation Scheduled-Date and Time
Insurance Authorization # and person giving Auth for Additional Imaging Studies
Pre-Op Scheduled Date and Time
Procedure Scheduled Date and Time
Scheduler with Whom Procedure Scheduled
Form Completed By

 

Copyright © 2005, CaroMont Health, Inc . All rights reserved.