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Facility Intake Form for Professional Imaging Mobile Dysphagia Consult

Facility Intake Form for Professional Imaging Mobile Dysphagia Consult 2025

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The document is a Facility Intake Form for scheduling a Mobile Dysphagia Consult, outlining required information and documentation needed to assess patients with swallowing difficulties. It includes sections for patient details, symptoms, medical history, and specific assessments needed for dysphagia evaluation. The form emphasizes the importance of completing all sections to avoid scheduling delays and requires signatures and consent from healthcare professionals.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Facility Name and City in the designated fields. Ensure that the person completing the form is clearly identified, along with their contact information.
Fill in the Ordering Physician's name and date. This section is crucial for processing your request efficiently.
In the SYMPTOMS section, check all applicable symptoms that pertain to the patient. This helps in understanding the medical reasons for consultation.
Indicate any status changes due to improvement or decline, and provide details on current diet and swallowing status.
Complete the CHECK ORDER PORTION by selecting necessary assessments required for a comprehensive dysphagia consultation.
Specify reasons for a mobile/onsite visit if applicable, ensuring all conditions are noted.
Finally, ensure that all signatures are obtained where required, including consent from the patient or legal guardian.

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