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HEMATOLOGY REFERRAL FORM http://albertsons.com/specialtycare Phone: 877.466.8028 Fax: 877.466.8040Patient InformationPatient Name: DOB: Sex: Phone: MFC ell Phone: Email Address: Address: City: State:

How to fill out hematology referral form

How to fill out hematology referral form

1. To fill out a hematology referral form, follow these steps:
2. Begin by filling out the patient's personal information, such as their name, date of birth, and contact details.
3. Provide the patient's medical history, including any previous diagnoses or treatments related to hematological conditions.
4. Indicate the reason for the referral, specifying the symptoms, concerns, or abnormal blood test results that warrant further investigation.
5. Include relevant laboratory test results, such as complete blood count (CBC), blood smear findings, and any other hematological tests conducted.
6. If there are any specific tests or procedures requested, make sure to mention them along with the reason for their necessity.
7. Mention the referring healthcare professional's name, contact information, and their specialty.
8. Ensure that the form is signed and dated by the referring healthcare professional.
9. Double-check all the information filled out on the form for accuracy and completeness.
10. Submit the completed form to the appropriate hematology department or specialist for further evaluation and consultation.

Who needs hematology referral form?

1. A hematology referral form is typically needed by healthcare professionals, such as primary care physicians, internists, pediatricians, or other specialists, who suspect or want to investigate hematological disorders in their patients.
2. Patients with abnormal blood test results, unexplained symptoms related to the blood or hematopoietic system, or those with a family history of blood disorders may also require a hematology referral form.
3. The form serves as a means of communication between the referring healthcare professional and the hematologist, facilitating the transfer of relevant patient information and ensuring continuity of care.

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