Get the free Thoracoamniotic Shunt Referral Form - University of Miami - obgyn med miami

Fetal Therapy Center. Thoracoamniotic Shunt Referral Form. PATIENT INFORMATION. SSN. —. Name. , Last. First. Address. City. State. ZIP. . Phone —. —. Fax ...

How to fill out thoracoamniotic shunt referral form

How to fill out thoracoamniotic shunt referral form:

1. Obtain the thoracoamniotic shunt referral form from the appropriate healthcare provider or medical facility.
2. Fill out the patient's personal information, including their name, date of birth, and contact details. Provide accurate and up-to-date information to ensure effective communication.
3. Include the patient's medical history, specifically related to the thoracoamniotic shunt procedure. Provide details about any prior surgeries, medical conditions, or medications the patient is currently taking.
4. Indicate the reason for the referral by stating the diagnosis or suspected condition that requires a thoracoamniotic shunt. It is essential to be clear and concise in describing the patient's medical need.
5. If applicable, provide any relevant supporting documentation, such as medical reports, test results, or imaging scans. These records can help healthcare providers better understand the patient's condition and determine the appropriate course of action.
6. Ensure that the referral form is signed and dated by the referring healthcare provider. A valid signature is necessary to authenticate the referral and facilitate seamless communication between medical professionals.
7. Submit the completed thoracoamniotic shunt referral form to the designated recipient or healthcare facility. Be aware of any specific submission instructions or requirements outlined on the form itself or provided by the referring healthcare provider.

Who needs thoracoamniotic shunt referral form:

1. Pregnant women diagnosed with fetal lung lesions that may benefit from a thoracoamniotic shunt.
2. Patients with suspected or confirmed fetal hydrops related to a thoracic condition, where a thoracoamniotic shunt may be an appropriate treatment option.
3. Individuals referred by their healthcare provider for further evaluation or management of thoracic anomalies in the fetus.

For pdfFiller’s FAQs

What is thoracoamniotic shunt referral form?

The thoracoamniotic shunt referral form is a document that is used to refer patients who require a thoracoamniotic shunt procedure. This form provides necessary information about the patient and their medical condition to the healthcare provider performing the procedure.

Who is required to file thoracoamniotic shunt referral form?

The thoracoamniotic shunt referral form is typically filled out and filed by the obstetrician or the healthcare provider responsible for the prenatal care of the patient.

How to fill out thoracoamniotic shunt referral form?

To fill out the thoracoamniotic shunt referral form, the healthcare provider needs to provide the patient's information such as name, age, gestational age, medical history, diagnostic test results, and reasons for recommending the thoracoamniotic shunt procedure.

What is the purpose of thoracoamniotic shunt referral form?

The purpose of the thoracoamniotic shunt referral form is to communicate the need for a thoracoamniotic shunt procedure to the healthcare provider who will perform the intervention. It ensures proper documentation and coordination of care for the patient.

What information must be reported on thoracoamniotic shunt referral form?

The thoracoamniotic shunt referral form should include the patient's personal information, gestational age, medical history, diagnostic test results, an explanation of the reasons for the referral, and any additional relevant information about the patient's condition.

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