OR OHSU Pediatric Patient Referral Form 2017-2025 free printable template

PEDIATRIC PATIENT REFERRAL FORM 2730 SW Moody Ave Portland, OR 97201 Phone 5034184332 5034184333School of Dentistry Department of Pediatric DentistryPlease fax to 503418433. Email Digital Rays to

How to fill out pediatric dental referral form

How to fill out OR OHSU Pediatric Patient Referral Form

1. Obtain the OR OHSU Pediatric Patient Referral Form from the OHSU website or the referring physician's office.
2. Fill in the patient's personal details including full name, date of birth, and insurance information.
3. Provide details about the referring physician, including name, contact number, and office address.
4. Describe the medical issue or condition that requires referral, including any relevant medical history.
5. Attach any necessary medical records or supporting documents that may aid in the referral process.
6. Sign and date the form, if required, to authorize the referral.
7. Submit the completed form through the specified method (fax, email, or mail) as indicated on the form.

Who needs OR OHSU Pediatric Patient Referral Form?

1. Patients who require specialized pediatric care that cannot be provided by their primary healthcare provider.
2. Parents or guardians seeking a second opinion or consultation for their child's medical condition.
3. Healthcare professionals needing to refer a pediatric patient to a specialist at OHSU.

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What is OR OHSU Pediatric Patient Referral Form?

The OR OHSU Pediatric Patient Referral Form is a document used for referring pediatric patients to Oregon Health & Science University (OHSU) for specialized medical care.

Who is required to file OR OHSU Pediatric Patient Referral Form?

Healthcare providers, such as pediatricians and family doctors, are required to file the OR OHSU Pediatric Patient Referral Form when referring a patient to OHSU for further evaluation or treatment.

How to fill out OR OHSU Pediatric Patient Referral Form?

To fill out the OR OHSU Pediatric Patient Referral Form, providers should provide patient personal information, medical history, the reason for referral, and any relevant diagnostic information or test results.

What is the purpose of OR OHSU Pediatric Patient Referral Form?

The purpose of the OR OHSU Pediatric Patient Referral Form is to facilitate the referral process for pediatric patients by gathering necessary information for the receiving specialist at OHSU, ensuring effective and timely care.

What information must be reported on OR OHSU Pediatric Patient Referral Form?

The OR OHSU Pediatric Patient Referral Form must report information such as the patient's personal details (name, date of birth), medical history, current medications, reason for referral, and any relevant laboratory or imaging results.