Get the free Comprehensive Epilepsy Clinic referral form 1-8-13 - childrensmercy

Comprehensive Epilepsy Clinic Referral Address: Name: Date of Birth: / / Preferred name/s: Sex: ? Male ? Female Preferred language: Phone: Mobile: Email: Alternative Contact: Period of referral: ?

How to fill out comprehensive epilepsy clinic referral

Who needs comprehensive epilepsy clinic referral?

1. Patients who have been experiencing seizures or related symptoms and require a more specialized evaluation and treatment for epilepsy.
2. Individuals who have been diagnosed with epilepsy but need a comprehensive assessment to determine the best course of treatment or medication adjustments.
3. People with complex or refractory epilepsy, meaning their seizures are difficult to control with current treatment methods.

How to fill out a comprehensive epilepsy clinic referral:

1. Start by gathering all relevant medical records, including previous EEGs, MRI or CT scan results, and any other diagnostic test reports related to the patient's seizures or epilepsy.
2. Contact the comprehensive epilepsy clinic where you wish to make the referral and inquire about their specific referral process. They may provide a referral form or request specific information to be included in the referral letter.
3. If a referral form is provided, ensure that all sections are filled out accurately and completely. This may include patient demographics, medical history, current medications, and reasons for the referral. If a referral letter is required instead, compile all necessary information in a clear and concise manner.
4. Include a detailed description of the patient's seizure history, including the frequency, duration, type, and any associated triggers or prodromal symptoms. If possible, provide specific examples or incidents where seizures occurred.
5. Describe previous treatments or medications tried, detailing their effectiveness and any side effects experienced. Mention any changes made in medication dosages or types and the patient's response to these adjustments.
6. Clearly state the reasons for the referral and what you hope to achieve by sending the patient to a comprehensive epilepsy clinic. This may include the need for a more specialized evaluation, consideration for epilepsy surgery, or an assessment for potential new therapies.
7. If relevant, include any comorbidities or other medical conditions that may impact the patient's epilepsy management or treatment options.
8. Ensure that all contact information, including the referring healthcare provider's name, address, phone number, and signature, is included in the referral form or letter.
9. Double-check all information for accuracy and completeness before submitting the referral. It may be helpful to have another healthcare provider review the referral for any potential errors or missing information.
10. Submit the completed referral form or letter as instructed by the comprehensive epilepsy clinic. Follow up with the clinic if necessary to ensure that they have received the referral and to inquire about any additional steps or information required.

For pdfFiller’s FAQs

What is comprehensive epilepsy clinic referral?

Comprehensive epilepsy clinic referral is a process where a patient with epilepsy is referred to a specialized clinic for thorough evaluation and treatment.

Who is required to file comprehensive epilepsy clinic referral?

Medical professionals such as neurologists, primary care physicians, or epilepsy specialists may file comprehensive epilepsy clinic referral.

How to fill out comprehensive epilepsy clinic referral?

Comprehensive epilepsy clinic referral can be filled out by providing the patient's medical history, current symptoms, and any previous treatments.

What is the purpose of comprehensive epilepsy clinic referral?

The purpose of comprehensive epilepsy clinic referral is to ensure that the patient receives specialized care and treatment for their epilepsy condition.

What information must be reported on comprehensive epilepsy clinic referral?

Information such as patient's medical history, current symptoms, previous treatments, and referring physician's contact information must be reported on comprehensive epilepsy clinic referral.

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