Get the free Bone Anchored Implant Referral Form - umanitoba

Bone Anchored Implant Program GB 421 820 Sherbrooke Street. Winnipeg, MB R3A 1R9. Referrals (Fax): 204 -787-1727. PATIENT REFERRAL FORM (fax or mail form to the ...

How to fill out bone anchored implant referral

How to fill out bone anchored implant referral:

1. Gather patient information: Start by collecting all necessary information about the patient who requires a bone anchored implant referral. This includes their full name, contact details, medical history, and any relevant diagnostic imaging reports.
2. Fill out the referring physician's information: Provide the name, contact information, and medical practice details of the referring physician who is recommending the bone anchored implant procedure.
3. Specify the reason for referral: Clearly state the reason why the patient requires a bone anchored implant. This could be due to hearing loss, conductive hearing disorders, or other specific indications where a bone anchored implant is a suitable treatment option.
4. Include relevant medical documentation: Attach any relevant medical reports, test results, or imaging studies to support the referral. This could include audiograms, CT scans, or previous surgical reports.
5. Outline previous treatments or interventions: Describe any previous treatments or interventions the patient has undergone for their hearing impairment. This could include hearing aids, surgeries, or alternative interventions that have been attempted.
6. Provide a summary of the patient's condition: Write a brief summary of the patient's current condition, including their symptoms, medical history, and any challenges they face due to their hearing impairment.
7. State desired outcomes and expectations: Clearly articulate the desired outcomes and expectations for the bone anchored implant procedure. This could include improved hearing ability, enhanced communication, or other specific goals that the patient hopes to achieve.
8. Include any additional notes or considerations: If there are any additional notes or considerations that may help the referring physician or the specialist reviewing the referral, include them in this section.

Who needs bone anchored implant referral?

1. Patients with conductive hearing disorders: Individuals who have been diagnosed with conductive hearing disorders, such as chronic ear infections, congenital malformations, or previous middle ear surgeries may require a bone anchored implant referral.
2. Individuals with single-sided deafness: Patients who experience single-sided deafness, where one ear is severely or profoundly impaired while the other ear has normal or near-normal hearing, may benefit from a bone anchored implant referral.
3. Candidates for mixed or sensorineural hearing loss: People who have mixed or sensorineural hearing loss, where there is a combination of conductive and inner ear hearing loss, may be suitable candidates for a bone anchored implant referral.
4. Those with limited success with traditional hearing aids: Patients who have tried traditional hearing aids but have not achieved satisfactory results in terms of hearing improvement or communication may require a bone anchored implant referral as an alternative solution.
5. Individuals with specific anatomical or medical considerations: Certain anatomical or medical conditions, such as malformed ear canals, chronic otitis externa, or severe skin allergies to hearing aid materials, may necessitate a bone anchored implant referral.

Remember, it is essential to consult with a qualified healthcare professional or an audiologist to determine individual candidacy for a bone anchored implant referral.

For pdfFiller’s FAQs

What is bone anchored implant referral?

Bone anchored implant referral is a process of referring a patient for a surgical procedure to implant a device that is anchored directly to the bone.

Who is required to file bone anchored implant referral?

Healthcare providers such as doctors, specialists, or surgeons are required to file bone anchored implant referral for their patients.

How to fill out bone anchored implant referral?

Bone anchored implant referral can be filled out by providing the patient's information, medical history, reason for referral, and any relevant test results.

What is the purpose of bone anchored implant referral?

The purpose of bone anchored implant referral is to provide patients with access to specialized surgical procedures that can improve their quality of life.

What information must be reported on bone anchored implant referral?

The information reported on bone anchored implant referral should include patient demographics, medical history, current symptoms, and any relevant diagnostic imaging.

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