Get the free Aerodigestive referral form - marcus

Aerodigestive referral form Phone: 404-785-1161 Fax: 404-785-9087 Thank you for your referral to Children's Healthcare of Atlanta. Please fill out this form and fax it to our office. Contact us with

How to fill out aerodigestive referral form

How to fill out an aerodigestive referral form:

1. Begin by filling out the patient's personal information, including their full name, date of birth, and contact information.
2. Provide the patient's medical history, including any relevant diagnoses and previous treatments.
3. Document any symptoms or issues the patient is experiencing related to the aerodigestive system, such as difficulty swallowing or recurrent respiratory infections.
4. Specify any additional tests or imaging studies that have been performed to evaluate the aerodigestive system.
5. Include the names and contact information of any other healthcare providers involved in the patient's care.
6. Indicate the reason for the referral to the aerodigestive team, such as suspicion of a congenital anomaly or the need for comprehensive evaluation and management.
7. If available, attach any relevant medical records, test results, or imaging reports that support the need for the referral.
8. Sign and date the form to confirm your authorization and understanding of the referral process.
9. Once completed, submit the form to the appropriate department or healthcare provider.

Who needs an aerodigestive referral form:

1. Patients who are experiencing complex or persistent symptoms related to the aerodigestive system, such as recurrent respiratory infections, chronic cough, or difficulty swallowing.
2. Individuals with congenital anomalies or structural abnormalities affecting the aerodigestive system.
3. Patients who require a comprehensive evaluation and management approach involving multiple healthcare providers, such as otolaryngologists, pulmonologists, gastroenterologists, and speech therapists.
4. Individuals who have undergone previous treatments or interventions that have not provided adequate relief or resolution of their aerodigestive symptoms.
5. Patients with suspected or confirmed aerodigestive disorders, such as laryngomalacia, tracheomalacia, or gastroesophageal reflux disease (GERD).
6. Infants and children who have feeding difficulties or failure to thrive due to aerodigestive issues.
7. Individuals with a history of recurrent aspiration or chronic lung disease that may be related to aerodigestive dysfunction.
8. Patients referred by other healthcare providers who require specialized evaluation and management of their aerodigestive issues.

Note: It is always best to consult with a healthcare provider or the specific aerodigestive team to determine if a referral form is appropriate for a particular case and to ensure that all necessary information is provided accurately.

For pdfFiller’s FAQs

What is aerodigestive referral form?

Aerodigestive referral form is a document used to request evaluation and treatment for patients with complex aerodigestive issues.

Who is required to file aerodigestive referral form?

Healthcare providers, such as primary care physicians, specialists, and therapists, are required to file aerodigestive referral forms.

How to fill out aerodigestive referral form?

Aerodigestive referral forms can typically be filled out electronically or by hand, and require detailed information about the patient's medical history, symptoms, and current treatment plan.

What is the purpose of aerodigestive referral form?

The purpose of aerodigestive referral form is to facilitate communication between healthcare providers, ensure comprehensive care for patients with aerodigestive issues, and streamline the referral process.

What information must be reported on aerodigestive referral form?

Aerodigestive referral forms typically require information such as patient demographics, medical history, current symptoms, previous treatments, and the reason for referral.

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