Get the free Deep Venous Thrombosis Referral Form New Patient Existing q

Deep Venous Thrombosis Referral Form q New Patient q Existing PATIENT INFORMATION STATEMENT OF MEDICAL NECESSITY Patient name: Diagnosis: SS# DOB: (mm×dd/YYY) q Male q Female ICD9 code: q Address:

How to fill out deep venous thrombosis referral

How to fill out a deep venous thrombosis referral:

1. Start by collecting the necessary information about the patient, including their full name, date of birth, contact information, and any relevant medical history.
2. Specify the reason for the referral clearly. In this case, mention that the referral is for suspected deep venous thrombosis.
3. Provide the date of when the referral is being filled out.
4. Next, identify the healthcare professional that the referral is being addressed to. Include their name, specialty, and contact information.
5. Outline the patient's symptoms and any specific concerns related to deep venous thrombosis. This helps the healthcare professional to understand the urgency and severity of the case.
6. If any diagnostic tests or imaging have been conducted, include the details of the tests, their results, and any relevant images or reports.
7. It is important to mention any previous treatments or interventions that have been carried out for the patient's condition.
8. Finally, sign and date the referral, ensuring that all the information provided is accurate and complete.

Who needs deep venous thrombosis referral?

1. Individuals who have symptoms such as swelling, pain, or tenderness in the legs or arms, which could be indicative of deep venous thrombosis.
2. Patients who have a history of deep venous thrombosis or other risk factors such as immobility, recent surgery, or a family history of the condition.
3. Those who have been found to have abnormal results in diagnostic tests like ultrasound or D-dimer, which suggest the presence of deep venous thrombosis.
4. Individuals who are at a higher risk of developing deep venous thrombosis due to certain medical conditions, such as cancer, obesity, or pregnancy.
5. Anyone experiencing sudden shortness of breath, chest pain, or any other symptoms of a pulmonary embolism, as deep venous thrombosis can lead to this life-threatening condition.

Remember, it is always best to consult with a healthcare professional or your primary care physician to determine whether a deep venous thrombosis referral is necessary.

For pdfFiller’s FAQs

What is deep venous thrombosis referral?

Deep venous thrombosis referral is a medical referral for patients suspected of having a blood clot in the deep veins of the body.

Who is required to file deep venous thrombosis referral?

Healthcare providers such as doctors, nurses, or medical professionals are required to file deep venous thrombosis referral.

How to fill out deep venous thrombosis referral?

Deep venous thrombosis referral can be filled out by providing the patient's medical history, symptoms, and test results to the healthcare provider.

What is the purpose of deep venous thrombosis referral?

The purpose of deep venous thrombosis referral is to diagnose and treat patients with blood clots in their deep veins to prevent complications such as pulmonary embolism.

What information must be reported on deep venous thrombosis referral?

On deep venous thrombosis referral, information such as patient demographics, medical history, symptoms, and diagnostic test results must be reported.

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