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How to use or fill out Consult Clinic Guidelines and Referral Form021517 docx with our platform
- Click ‘Get Form’ to open the Consult Clinic Guidelines and Referral Form021517 in the editor.
- Begin by filling out the 'Patient Information' section. Enter the patient's last name, first name, age, date of birth, and home address. Ensure all details are accurate for proper identification.
- Indicate whether the patient is new to Texas Children’s by selecting 'YES' or 'NO'. If applicable, provide the TCH Medical Record Number.
- Complete the 'Parent/Guardian Information' section with relevant contact details including names and phone numbers. Specify if an interpreter is needed and what language.
- In the 'Referring Physician Contact Information' section, fill in the physician's name, email address, mailing address, and contact numbers to ensure seamless communication.
- Detail any significant medical history in the provided fields. This includes reasons for referral, health problems, surgical procedures, allergies, and family history.
- Once completed, review all entries for accuracy before submitting your form via fax to 713-396-1995 as instructed at the bottom of the document.
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