Urogynecology-Reconstructive Pelvic Surgery-Request For Evaluation Form-Medical Center printable pdf download

Office Use Only

Provider: ______________________________

Appt. Date: ____________________________

Urogynecology/Reconstructive Pelvic Surgery

POL & HQUEST info given: _______________

Request for Evaluation

Testing: _______________________________

Notes: ________________________________

Phone: (603) 653-9312

Fax: (603) 650-0902

Urgent: call Physician Connection Line at 1-866-346-2362 or 603-653-9312

Stable

Please complete patient information below, or attach patient demographic information before faxing.

Patient’s Name: Last _________________________________ First _____________________________ MI ______________

DOB: _____________________________ SSN: _________ - ________ - _________ MR #: ____________________________

Address: _______________________________________________ City, ST: _________________________ Zip: ____________

Home Phone: ____________________________________________ Work Phone: _____________________________________

Name of Insurance: ___________________________ ID #: ____________________

Yes

Insurance Referral Required?

Referring Provider: _______________________________________________ Office Phone: ____________________________

Contact Name: ___________________________________________________ Office Fax: ______________________________

Address: __________________________________________________________________________________________________

Would you like notification of the appointment?

Yes

Symptoms: ________________________________________________________________________________________________

How long has patient been symptomatic? _______________________________________________________________________

Past pelvic/incontinence surgery? ______________________________________________________________________________

Is this Worker’s Comp related?

Yes

Diagnosis (please check all that apply and circle all known conditions):

Pelvic organ prolapse (uterine prolapse, vaginal prolapse,

Voiding dysfunction (urinary retention, difficulty voiding,

cystocele, rectocele, enterocele, unknown)

unknown)

Urinary incontinence (stress incontinence, overactive bladder,

Anal incontinence (neurogenic, sphincter damage,

mixed, frequency or urgency, overflow incontinent,

unknown)

functional incontinence, unknown)

Genital fistula (vesicovaginal fistula, rectovaginal fistula,

Difficulty with defecation

unknown)

Reason for request (please check one):

Consultation regarding condition(s) above and management options.

Evaluation of condition and treatment only for specific recommendations (i.e., for urodynamic testing only; or for pessary

fitting only with ongoing at referring office; or only if certain surgeries are recommended – please specify what you want us to

treat versus what you would treat): _____________________________________________________________________________

__________________________________________________________________________________________________________

Referral to evaluate and treat condition(s) above.

Second opinion

Before faxing this referral form, please check the following information which is included

so that we may process your referral in a timely fashion.

Pertinent records from prior surgeries

Op notes

Prior evaluations and/or testing (i.e., urinalysis,

Insurance referral (if required)

Medical history

urine cultures, urodynamic testing, etc.)

One Medical Center Drive | Lebanon, NH 03756 | Tel: (603) 650-5000 |

Rev. 4-1-10

Urogynecology-Reconstructive Pelvic Surgery-Request For Evaluation Form-Medical Center

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