Get the free Outpatient Dysphagia Clinic Referral - Alberta Health Services

Outpatient Dysphagia Clinic Referral The Outpatient Dysphagia Clinic specializes in the assessment and management of pharyngeal dysphagia. We do not assess esophageal or gastric dysfunction. Please

How to fill out outpatient dysphagia clinic referral

How to fill out an outpatient dysphagia clinic referral:

1. Fill in the patient's personal information, including their name, date of birth, contact information, and insurance details.
2. Indicate the referring physician's information, including their name, clinic or hospital name, contact information, and any specialty or credentials relevant to the referral.
3. Include the reason for the referral, specifying that it is for dysphagia evaluation and treatment. Provide a brief summary of the patient's symptoms or medical history that led to the referral.
4. Mention any relevant medical records or test results that should accompany the referral, such as previous imaging studies or swallowing assessments.
5. Provide a brief note on the urgency of the referral, if applicable.
6. Sign and date the referral form, ensuring that it is legible and includes your contact information in case the clinic needs to reach you for further information or clarification.

Who needs an outpatient dysphagia clinic referral?

1. Patients experiencing difficulty swallowing (dysphagia) who require further evaluation, diagnosis, and treatment options should consider seeking a referral to an outpatient dysphagia clinic.
2. Individuals who have been diagnosed with certain conditions or undergone medical treatments that may affect their swallowing function, such as stroke, head and neck cancer, neurodegenerative diseases, or recent surgery.
3. Patients who have persistent swallowing difficulties that impact their nutrition, hydration, or overall quality of life, and have not responded adequately to conservative management or primary care interventions may benefit from a referral to a specialized outpatient dysphagia clinic.

For pdfFiller’s FAQs

What is outpatient dysphagia clinic referral?

Outpatient dysphagia clinic referral is a recommendation for a patient to receive evaluation and treatment for swallowing difficulties on an outpatient basis.

Who is required to file outpatient dysphagia clinic referral?

Healthcare providers such as physicians, speech-language pathologists, and other members of the medical team may be required to file outpatient dysphagia clinic referral.

How to fill out outpatient dysphagia clinic referral?

To fill out an outpatient dysphagia clinic referral, healthcare providers must include the patient's demographics, medical history, current symptoms, and reason for referral.

What is the purpose of outpatient dysphagia clinic referral?

The purpose of outpatient dysphagia clinic referral is to ensure that patients with swallowing difficulties receive a comprehensive evaluation and appropriate treatment from a specialized clinic.

What information must be reported on outpatient dysphagia clinic referral?

Information such as patient demographics, medical history, current symptoms related to swallowing difficulties, and reasons for referral must be reported on outpatient dysphagia clinic referral.

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