Get the free Adolescent Medicine Referral Form - Texas Children's Hospital - texaschildrens

Preferred Location: Texas Medical Center West Campus Appointment Request and Clinical Triage Form Texas Children's Adolescent & Young Women's Clinic Phone: (832) 822-4887 Fax: (832) 825-8950 Date

How to fill out adolescent medicine referral form

Point by point instructions to fill out adolescent medicine referral form:

1. Begin by clearly stating the purpose of the referral form at the top. Include information on what the referring physician is seeking from the adolescent medicine specialist.
2. Next, provide the contact information of the referring physician or healthcare facility. This should include the name, address, phone number, and any other relevant details.
3. Include the contact information of the adolescent patient, such as their full name, date of birth, address, and contact number. It is important to double-check the accuracy of this information to ensure proper communication.
4. In the referral form, there should be a section to outline the reason for the referral. This can include the specific medical condition, symptoms, or concerns that require attention from an adolescent medicine specialist.
5. Additionally, provide a detailed medical history of the patient. Include information about any previous diagnoses, treatments, medications, or allergies that may be relevant to the referral.
6. If there are any specific tests or medical records that need to be shared with the adolescent medicine specialist, clearly state this in the referral form. Provide details on where the records can be accessed or instructions on how to send them.
7. Mention any specific preferences or requirements for the referral, such as the need for an urgent appointment or a preferred specialist within the adolescent medicine field.
8. Finally, ensure that all sections of the referral form are complete and legible. Verify that the form is signed and dated by the referring physician or healthcare provider.

Who needs adolescent medicine referral form?

1. Adolescents who require specialized medical care for conditions that specifically affect this age group, such as puberty-related concerns, mental health issues, reproductive health, or substance abuse problems.
2. Referring physicians or primary care providers who believe that an adolescent patient would benefit from the expertise of an adolescent medicine specialist in managing their healthcare needs.
3. Parents or guardians of adolescents who are seeking a second opinion or specialized care for their child's health concerns, and have been advised to seek out an adolescent medicine specialist by their current healthcare provider.

For pdfFiller’s FAQs

What is adolescent medicine referral form?

Adolescent medicine referral form is a document used to refer a young person to a specialist in adolescent medicine for further evaluation and treatment.

Who is required to file adolescent medicine referral form?

Health care providers, school counselors, or parents/guardians may be required to file adolescent medicine referral form depending on the situation.

How to fill out adolescent medicine referral form?

The form typically requires basic information about the adolescent, reason for referral, medical history, and any relevant symptoms.

What is the purpose of adolescent medicine referral form?

The purpose of adolescent medicine referral form is to ensure that adolescents receive appropriate medical care from specialists who are trained to address their unique needs.

What information must be reported on adolescent medicine referral form?

Information such as patient's name, date of birth, contact information, reason for referral, medical history, and any relevant symptoms must be reported on the form.

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