Get the free Reconstructive Pelvic Surgery Referral Form

Dartmouth Hitchcock Medical Interphone:Fax:Medically Urgent Fax:(603) 6539312 (603) 6764080 (603) 6401909Referring Provider: ___ Office Phone: ___ Practice Name: ___ Fax: ___ Practice Address ___PCP

How to fill out reconstructive pelvic surgery referral

How to fill out reconstructive pelvic surgery referral

1. Obtain the necessary referral form from the healthcare provider who is recommending the reconstructive pelvic surgery.
2. Fill out the patient's demographic information, including name, address, date of birth, and contact information.
3. Provide the reason for the referral and a brief medical history of the patient.
4. Include any relevant test results or imaging studies that support the need for reconstructive pelvic surgery.
5. Provide any other pertinent information that will help the receiving healthcare provider understand the patient's case and the need for surgery.
6. Submit the completed referral form to the appropriate healthcare provider or facility as instructed.

Who needs reconstructive pelvic surgery referral?

1. Individuals who are experiencing pelvic floor dysfunction or other conditions that may require reconstructive surgery may need a referral for reconstructive pelvic surgery.
2. It is often recommended by gynecologists, urologists, or colorectal surgeons for patients with pelvic organ prolapse, urinary incontinence, or other pelvic floor disorders.

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What is reconstructive pelvic surgery referral?

Reconstructive pelvic surgery referral is the process by which a physician refers a patient to a specialist for surgical treatment of pelvic floor disorders.

Who is required to file reconstructive pelvic surgery referral?

Any physician who believes their patient may benefit from reconstructive pelvic surgery is required to file a referral.

How to fill out reconstructive pelvic surgery referral?

To fill out a reconstructive pelvic surgery referral, the physician must provide detailed information about the patient's medical history and the reason for the referral.

What is the purpose of reconstructive pelvic surgery referral?

The purpose of reconstructive pelvic surgery referral is to connect patients with specialists who can provide surgical treatment for pelvic floor disorders.

What information must be reported on reconstructive pelvic surgery referral?

Reconstructive pelvic surgery referral must include the patient's medical history, reason for referral, and any relevant test results or imaging studies.