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REQUISITION FORM FOR VIDEO FLUOROSCOPIC SWALLOWING ASSESSMENT PATIENT INFORMATION Name:___Preferred Name:___Sex (as per SHIP)Female Mandate of Birth:___ / ___ / ___Health Card Number:___Day MonthIdentifies
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Begin by entering the required information, such as the patient's name, date of birth, and contact details.
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Fill out the medical history section, providing any relevant information about the patient's swallowing issues.
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The requisition-form-wh-swallowing-clinic.pdf is needed by patients who require medical attention for swallowing issues. This form is typically used to gather relevant information about the patient's condition and help healthcare professionals assess and provide appropriate treatment or diagnostic services for swallowing disorders.
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The requisition-form-wh-swallowing-clinicpdf is a document used for requesting services or information related to swallowing assessments or treatments at a specialized clinic.
Healthcare professionals, such as doctors or specialists, who need to refer patients for swallowing evaluations or therapies are required to file the requisition form.
To fill out the requisition form, provide the patient's information, reason for referral, relevant medical history, and any specific evaluation requests.
The purpose of the requisition form is to facilitate the referral process for patients needing swallowing assessments, ensuring that all necessary information is communicated to the clinic.
The form typically requires patient demographics, contact information, medical history, specific swallowing issues, and the referring healthcare provider's details.
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