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OU Medicine Liver/Transplant Surgery Referral - Adult & Pediatric 2019-2025 free printable template

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940 NE 13th Street s Suite 2000 s Oklahoma City, OK 73104 Phone (405) 2717498 / Toll Free (877) 8176911 or 8887777081 / Fax (405) 2714329 REFERRAL INTAKE COORDINATOR: Jean Kay, Wanda Price and/or
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How to fill out OU Medicine Liver/Transplant Surgery Referral - Adult

01
Obtain the OU Medicine Liver/Transplant Surgery Referral form.
02
Fill in the patient's personal information, including name, date of birth, and contact details.
03
Provide the referring physician's information, including name, contact number, and practice details.
04
Include the patient's medical history related to liver conditions, as well as any relevant test results.
05
Specify the reason for the referral and any particular assessments or treatments desired.
06
Sign and date the referral form, ensuring all required fields are completed.
07
Submit the referral form to OU Medicine via fax or secure online submission portal.

Who needs OU Medicine Liver/Transplant Surgery Referral - Adult?

01
Patients with end-stage liver disease requiring evaluation for transplant.
02
Individuals with severe liver conditions that need specialized surgical intervention.
03
Those experiencing complications from liver disease that necessitate referral to a transplant center.
04
Patients being considered for liver transplant due to conditions like cirrhosis, liver cancer, or acute liver failure.
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OU Medicine Liver/Transplant Surgery Referral - Adult is a formal document used by healthcare providers to refer adult patients to specialized liver and transplant surgical services at OU Medicine.
Healthcare providers, including primary care physicians and specialists, are required to file the OU Medicine Liver/Transplant Surgery Referral - Adult for patients who need evaluation for liver transplant or surgical interventions.
To fill out the OU Medicine Liver/Transplant Surgery Referral - Adult, providers should complete sections detailing patient demographics, medical history, relevant laboratory results, and any prior imaging studies that may assist in evaluating the patient's condition.
The purpose of the OU Medicine Liver/Transplant Surgery Referral - Adult is to initiate the process for specialized evaluation and management of adults with liver diseases or conditions requiring transplant surgery.
The referral must include the patient's full name, date of birth, contact information, medical history, current medications, results of any relevant tests, and the reason for the referral.
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