Get the free Lung and Heart/Lung Transplant Program Patient Referral Form - dukehealth

This form collects demographic and clinical information for patients referred to Duke's Lung and Heart/Lung Transplant Program, including insurance details and necessary medical history.

How to fill out lung and heartlung transplant

How to fill out Lung and Heart/Lung Transplant Program Patient Referral Form

1. Obtain the Lung and Heart/Lung Transplant Program Patient Referral Form from the appropriate medical institution or website.
2. Fill in the patient's personal information, including name, date of birth, address, and contact details.
3. Provide the patient's medical history, including diagnosis and any relevant treatments or surgeries.
4. Include information on the patient's current medications and any allergies.
5. Fill out the referring physician's information, including name, specialty, and contact information.
6. Attach any additional documents or test results that may support the referral.
7. Review the form for completeness and accuracy.
8. Submit the form to the Lung and Heart/Lung Transplant Program via the specified method (email, fax, or physical mail).

Who needs Lung and Heart/Lung Transplant Program Patient Referral Form?

1. Patients diagnosed with end-stage lung disease or heart disease.
2. Individuals who have been evaluated and deemed appropriate candidates for lung or heart/lung transplantation.
3. Healthcare providers or physicians who determine that a patient may benefit from a transplant evaluation.

People Also Ask about

What disqualifies you from getting a lung transplant?

Increasing Your Eligibility for a Lung Transplant Avoiding alcohol and drugs. Documenting that you have not used any nicotine product for at least six months, including vaping. Maintaining a BMI (body mass index) of 35 or less. Securing a strong social network to support you before, during and after lung transplantation.

What are the indications for lung transplant referral and listing?

Disease specific indications for referral and listing ❖ COPD; ❖ Alpha-1 antitrypsin deficiency; ❖ Lymphangioleiomyomatosis (LAM); ❖ Sarcoidosis with mean pulmonary artery pressure ≤30 mmHg; ❖ Bronchiectasis including primary ciliary dyskinesia.

What are the criteria for getting a lung transplant?

Being a lung transplant candidate includes having end-stage lung disease AND the following: Physical ability to survive for 90 days following transplant. Medical likelihood that you will survive 5 years after transplant. High risk of death if lung transplant is not performed within 2 years.

What are the indications for lung transplant referral?

However, some characteristics to consider for lung transplant referral include: End-stage lung disease limiting life expectancy or producing significant disability. Lung disease that is refractory to other medical or surgical therapies. No active contraindication to transplant. No malignancy within the past two years.

When to refer to a lung transplant?

Most major lung diseases that may lead to transplant have their own guidelines for when transplant surgery evaluation is appropriate. However, some characteristics to consider for lung transplant referral include: End-stage lung disease limiting life expectancy or producing significant disability.

For pdfFiller’s FAQs

What is Lung and Heart/Lung Transplant Program Patient Referral Form?

The Lung and Heart/Lung Transplant Program Patient Referral Form is a document used to refer patients for evaluation and potential inclusion in a transplant program for lung or heart/lung transplantation.

Who is required to file Lung and Heart/Lung Transplant Program Patient Referral Form?

The form is typically required to be filed by healthcare providers or specialists who are referring patients for a lung or heart/lung transplant evaluation.

How to fill out Lung and Heart/Lung Transplant Program Patient Referral Form?

To fill out the form, the referring physician or provider should provide patient demographics, medical history, current health status, and any relevant test results that support the referral for transplantation.

What is the purpose of Lung and Heart/Lung Transplant Program Patient Referral Form?

The purpose of the form is to gather essential information about the patient to determine their eligibility for lung or heart/lung transplantation and to facilitate the referral process to the transplant center.

What information must be reported on Lung and Heart/Lung Transplant Program Patient Referral Form?

The form typically requires information such as the patient's personal details, medical history, current medications, results from relevant diagnostic tests, and any previous treatments related to lung or heart conditions.