Get the free Coagulation Diagnostic Referral Form - dhmc

DIAGNOSTIC COAGULATION CENTER Outpatient Consultation Referral Form Phone: (603) 650-6763 Fax: (603) 650-6786 Referring Provider: Patient Name: Name of Guardian/Parent if

How to fill out coagulation diagnostic referral form

How to fill out coagulation diagnostic referral form:

1. Start by providing your personal information such as your full name, date of birth, and contact details.
2. Next, indicate the reason for the referral and provide any relevant medical history or symptoms that prompted the need for a coagulation diagnostic.
3. Specify any previous diagnostic tests or treatments related to coagulation that have been done, along with the dates and results, if applicable.
4. If you have any known allergies or medical conditions that may affect the diagnostic process or interpretation of results, make sure to mention them.
5. List any medications you are currently taking, including over-the-counter drugs, supplements, or herbal remedies, as they may potentially influence the coagulation diagnostic.
6. Indicate the name and contact details of your referring physician or healthcare provider who is requesting the coagulation diagnostic.
7. Finally, sign and date the form to confirm that all the information provided is accurate and complete.

Who needs coagulation diagnostic referral form?

1. Patients experiencing unexplained bleeding or clotting disorders may need a coagulation diagnostic referral form.
2. Individuals with a family history of coagulation disorders or a known genetic predisposition to such conditions may also require this form.
3. Patients who have undergone surgery or are about to undergo surgery may need to have their coagulation levels assessed prior to the procedure, making the referral form necessary.
4. Individuals with chronic diseases or certain medical conditions like liver disease, kidney disease, or autoimmune disorders that may affect the coagulation process may also necessitate a coagulation diagnostic referral form.

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What is coagulation diagnostic referral form?

The coagulation diagnostic referral form is a document used to refer a patient for diagnostic coagulation testing.

Who is required to file coagulation diagnostic referral form?

Healthcare providers and clinicians are required to file the coagulation diagnostic referral form for their patients.

How to fill out coagulation diagnostic referral form?

The form should be completed with the patient's personal information, relevant medical history, and the specific coagulation tests requested.

What is the purpose of coagulation diagnostic referral form?

The purpose of the coagulation diagnostic referral form is to facilitate the testing and diagnosis of coagulation disorders in patients.

What information must be reported on coagulation diagnostic referral form?

The form should include the patient's name, date of birth, healthcare provider's contact information, reason for referral, and requested coagulation tests.