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Print Form REFERRAL FOR INSTRUMENTAL SWALLOW STUDY District/School Name Address Phone TO: (Physician s name) FROM: (name and title) RE: REFERRAL FOR INSTRUMENTAL SWALLOW STUDY for Name DOB Address

How to fill out referral for instrumental swallow

How to fill out a referral for instrumental swallow:

1. Contact the appropriate healthcare provider or specialist who can perform an instrumental swallow evaluation. This may include a speech-language pathologist or a radiologist.
2. Provide the necessary information when filling out the referral, such as the patient's full name, contact information, and any identification numbers or insurance information required.
3. Specify the reason for the referral, stating that it is for an instrumental swallow evaluation. This helps the healthcare provider understand the purpose of the referral and ensures the appropriate assessment is conducted.
4. Include relevant medical history or background information about the patient that may be helpful for the evaluating healthcare provider. This can include any previous swallowing difficulties, surgeries, or relevant medical conditions.
5. If available, attach any relevant medical documents or test results that may support the need for an instrumental swallow evaluation. This could include previous swallow studies, imaging reports, or medical notes.
6. Clearly state the desired date or timeframe for the evaluation, if applicable. This helps the healthcare provider prioritize the referral and schedule the assessment in a timely manner.

Who needs a referral for instrumental swallow?

1. Individuals who experience difficulty swallowing or have dysphagia symptoms may need a referral for an instrumental swallow evaluation. This can include individuals who have recently undergone surgery involving the head and neck, those with neurological conditions such as stroke or Parkinson's disease, or individuals with suspected swallowing disorders.
2. Patients with chronic conditions that may affect their swallowing ability, such as muscular dystrophy or esophageal disorders, may also require a referral for instrumental swallow evaluation.
3. The referral may be necessary for patients who have either failed a previous swallow assessment or require further evaluation due to ongoing swallowing problems.

Remember, it is important to consult with the relevant healthcare professional or specialist to determine if a referral for an instrumental swallow evaluation is necessary for a specific individual.

For pdfFiller’s FAQs

What is referral for instrumental swallow?

Referral for instrumental swallow is a medical order written by a healthcare provider to request a diagnostic procedure that allows visualization of the swallowing mechanism.

Who is required to file referral for instrumental swallow?

A healthcare provider such as a physician, speech-language pathologist, or otolaryngologist is required to file a referral for instrumental swallow.

How to fill out referral for instrumental swallow?

Referral for instrumental swallow should include patient's demographics, medical history, reason for referral, and signature of the healthcare provider.

What is the purpose of referral for instrumental swallow?

The purpose of referral for instrumental swallow is to evaluate and diagnose swallowing disorders or dysphagia.

What information must be reported on referral for instrumental swallow?

Information such as patient's name, date of birth, insurance information, referring healthcare provider, and reason for referral must be reported on a referral for instrumental swallow.

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