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LOS ANGELES FETAL THERAPY PROGRAM CARDIAC TWIN REFERRAL QUESTIONNAIRE DATE PATIENT DOB Maternal Weight Cell Phone PHYSICIAN EDC EGA Twins Triplets PHYSICIAN PHONE NO. FAX NO. PHYSICIAN ADDRESS CITY/STATE
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How to fill out la-fetal-formrapy-acardiac-and-anomalous-twin-referral-form-061814 - losangelesfetalt
Who needs la-fetal-formrapy-acardiac-and-anomalous-twin-referral-form-061814 - losangelesfetalformrapy?
Pregnant individuals who have been diagnosed with a acardiac or anomalous twin and require specialized fetal therapy in Los Angeles.
How to fill out la-fetal-formrapy-acardiac-and-anomalous-twin-referral-form-061814 - losangelesfetalformrapy:
01
Start by providing your personal information in the designated sections of the form. This includes your name, contact details, and any other required demographic information.
02
Next, indicate the healthcare provider who is referring you for the fetal therapy by filling in their name, contact information, and their specialized field or specialty.
03
Specify the reason for the referral. In this case, mention the diagnosis of an acardiac or anomalous twin and the need for specialized fetal therapy.
04
If applicable, provide any relevant medical history or previous treatments related to your condition. This can help the healthcare provider better understand your situation and provide appropriate care.
05
Indicate any current medications or allergies that the healthcare provider should be aware of to ensure safe treatment and management of your condition.
06
If you have insurance coverage, provide your insurance information including policy number, group number, and any other relevant details. If you do not have insurance, you may need to indicate this on the form as well.
07
Finally, sign and date the form to acknowledge that the information provided is accurate to the best of your knowledge.
Remember that it is essential to fill out the form completely and accurately to ensure proper evaluation and prompt scheduling of your appointment for fetal therapy in Los Angeles.
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What is la-fetal-formrapy-acardiac-and-anomalous-twin-referral-form-061814 - losangelesfetalformrapy?
This form is a referral form for acardiac and anomalous twin pregnancies in Los Angeles for fetal therapy.
Who is required to file la-fetal-formrapy-acardiac-and-anomalous-twin-referral-form-061814 - losangelesfetalformrapy?
Healthcare providers and medical facilities involved in the care of patients with acardiac and anomalous twin pregnancies in Los Angeles.
How to fill out la-fetal-formrapy-acardiac-and-anomalous-twin-referral-form-061814 - losangelesfetalformrapy?
The form must be completed with all relevant patient and provider information, including medical history, diagnostic tests, and reason for referral to fetal therapy.
What is the purpose of la-fetal-formrapy-acardiac-and-anomalous-twin-referral-form-061814 - losangelesfetalformrapy?
The purpose of this form is to facilitate the referral process for patients with acardiac and anomalous twin pregnancies to specialized fetal therapy services in Los Angeles.
What information must be reported on la-fetal-formrapy-acardiac-and-anomalous-twin-referral-form-061814 - losangelesfetalformrapy?
The form should include patient demographics, medical history, ultrasound findings, diagnostic tests, current treatments, and reason for referral to fetal therapy.
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