Ttts Siugr Referral Form – Fill Out and Use This PDF

Ttts Siugr Referral Form – Fill Out and Use This PDF

Ttts Siugr Referral Form PDF Details

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Ttts Siugr Referral Form PDF Details

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Ttts Siugr Referral Form PDF Details

Are you familiar with the referral process? If not, it's important to understand how this works so that you can make sure your patients are getting the most appropriate care. The purpose of the TTTS Sieger Referral Form is to ensure that each patient receives quality and individualized care in precise accordance with their needs. This form assists medical practitioners in assessing a patient's condition prior to determining what type of treatment or guidance should be recommended for optimal results. With its detailed questions, structured format and thoughtful approach, this form provides an efficient way for providers to determine diagnosis when dealing with complex medical problems. Read on to learn more about how completing this Referral Form can benefit both provider and patient!

Question	Answer
Form Name	Ttts Siugr Referral Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	E-mail, amazon, Hydrops, Unk

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University of Miami/Jackson Memorial Hospital

Fetal Therapy Center

Twin Twin Transfusion Syndrome (TTTS) / Selective

Intrauterine Growth Retardation (SIUGR) Referral Form

PATIENT INFORMATION

Name

DOB (MM/DD/YY)

Last

First

SSN

Address

Phone

City

State

ZIP

Cell

E-mail

Fax

Employer

Work Phone

Employer Address

Mother's Maiden Name

Race

Country of Birth

Religion

Marital Status

Emergency Contact/Next of Kin

Relationship

Phone

Cell

INSURANCE INFORMATION

PPO

HMO

Medicaid

Patients relationship to subscriber:

Self

Spouse

Child

Other

Insurance Provider

If other than self: Primary subscriber name?

Policy #

DOB (MM/DD/YY)

Group #

SSN

Insurance Phone

PHYSICIAN INFORMATION

Referring Perinatologist

Phone

Last

First

Fax

Physician Address

City

State

ZIP

E-mail

Referring Ob/Gyn

Phone

Last

First

Fax

Physician Address

City

State

ZIP

E-mail

PLEASE PRINT FORM AND FAX TO (305) 357-5675

ALL PRENATAL RECORDS, LABS, AND ULTRASOUNDS ARE REQUIRED WITH SUBMISSION

Progress Notes

Recent Ultrasound Reports

Date (MM/DD/YY)

Recent Labs

Copy of Insurance Card

FOR UM/JMH FTC USE ONLY:

Date Received (MM/DD/YY)

Diagnosis

Recommendation

Follow Up

TTTS/SIUGR Referral Form - Rev 08/10

Page 1 of 2

MEDICAL INFORMATION

DATE (MM/DD/YY)

AGE

GRAV

PARITY

LMP

EDC

GA: weeks

days

Twins

Triplets

Maternal Weight

lbs

Placental Location:

Fundal

Posterior

Amniotic Fluid

DONOR

RECIPIENT

Cervical Length

Maximum vertical pocket

Cervical length via

Estimated fetal weight

transvaginal ultrasound:

Funneling?

Yes

Amniocentesis

Genetic

Therapeutic

Yes

If yes, karyotype

46, XX

46, XY

Unk

No	If a therapeutic amniocentesis has been performed, please provide the following information:

Disruption of

Gross Rupture of

Date

Amount

Fluid

Placenta

Outer Membrane

dividing

Membranes

Chorio-

Placental

MM/DD/YY

Removed

Color

Penetrated

Detachment

membrane

(PROM)

Amnionitis

Abruption

Yes

Genetic Screening:

Trisomy 13/18 Trisomy 13/18

	Chorionicity
:	Mono/Di	Di/Di	Unk
:	Mono/Mono	Di/Tri
:	Mono/Mono	Di/Tri

Doppler Studies

Umbilical artery: AEDV REDV

Ductus Venosus- Reverse Flow Umbilical vein pulsatile

DONOR

Yes No

RECIPIENT

Yes No

Donor urinary bladder visible?

Incompetent Cervix

History of an incompetent cervix? Cerclage in current pregnancy?

Yes

Fetal Hydrops

Abdominal ascites

Scalp edema

Pleural effusion Pericardial effusion

Yes

Yes	No
Yes	Pre-term Labor
Yes	No
	Symptoms of pre-term labor?	Yes	No
Yes	No
	List symptoms
Yes	No
Yes	No

Abnormal Intracranial U/S Findings

Intraventricular hemorrhage	Yes	No
Porencephalic cysts	Yes	No
Ventriculomegaly	Yes	No

Medical History

Please list any pertinent medical conditions, including bleeding disorders

Medications

		Medications for pre-term labor		Yes	No
Yes	No	administered?
Yes	No
		List medications
Yes	No
Yes	No
Yes	No
	How did you hear about us?		Insurance provider list
	How did you hear about us?
	Referral		Media
	Name?		Brochure/flyer/mailing

	Website		Other

TTTS/SIUGR Referral Form - Rev 08/10

Page 2 of 2

How to Edit Ttts Siugr Referral Form Online for Free

When using the online tool for PDF editing by FormsPal, it is easy to fill in or alter Porencephalic right here. The editor is constantly updated by us, receiving additional functions and turning out to be greater. Getting underway is effortless! Everything you need to do is stick to these basic steps directly below:

Step 1: Press the orange "Get Form" button above. It will open up our pdf tool so that you could begin filling out your form.

Step 2: With the help of our state-of-the-art PDF editor, you can accomplish more than merely fill out blank form fields. Try all of the features and make your documents seem high-quality with customized text put in, or optimize the file's original content to perfection - all that supported by the capability to incorporate your personal photos and sign the file off.

This document will need particular data to be filled out, hence be certain to take the time to enter what's requested:

1. To start off, when completing the Porencephalic, start in the page that features the next fields:

2. Just after the prior part is completed, go to type in the applicable information in these - Referring Perinatologist, Physician Address, City, Email, Referring ObGyn, Physician Address, City, Email, Last, State, First, ZIP, Last, First, and State.

Always be extremely careful when filling in State and Physician Address, as this is where a lot of people make a few mistakes.

3. This third stage is simple - complete all of the empty fields in Recommendation, TTTSSIUGR Referral Form Rev, Follow Up, and Page of to complete the current step.

Hydrops writing process detailed (step 3)

4. Completing DATE MMDDYY, AGE, GRAV, PARITY, LMP, EDC, GA weeks, days, Twins, Triplets, Maternal Weight, lbs, Placental Location, Anterior, and Fundal is essential in the fourth stage - make sure to take the time and fill out each and every blank!

Hydrops completion process shown (part 4)

5. This form must be finalized with this particular section. Below one can find a full list of form fields that need specific information for your document submission to be faultless: Yes, Yes, Genetic Screening, NT Screen, Quad screen ONTD, Down Syndrome, Down Syndrome, Yes, Yes, Yes, Yes, Yes, Yes, Yes, and Yes.

Step 3: Prior to finalizing the form, check that all blanks are filled out the proper way. When you think it's all fine, click on “Done." Right after setting up afree trial account at FormsPal, it will be possible to download Porencephalic or send it via email directly. The PDF file will also be at your disposal through your personal account with your modifications. FormsPal guarantees your data privacy with a secure system that never records or distributes any type of personal data used in the form. Feel safe knowing your files are kept protected when you use our tools!

Down Syndrome

Quad screen

Down Syndrome

Quad screen