Get Abnormal Pap/colposcopy Evaluation Form - Med Dartmouth-hitchcock

Filling out the Abnormal Pap/Colposcopy Evaluation Form is a crucial step for referring patients for further evaluation. This guide provides detailed instructions to help you complete the form accurately and efficiently online.

Follow the steps to accurately complete the form.

1. Press the ‘Get Form’ button to access the Abnormal Pap/Colposcopy Evaluation Form and open it in the editor.
2. Begin by entering the patient’s name in the designated field. Ensure you also fill in the Medical Record Number (MRN) to assist with patient identification.
3. Provide the patient’s mailing address, including street, city, state, and zip code. This information is vital for any necessary correspondence.
4. Input the patient’s contact numbers, including home, work, and cell phone. This allows for effective communication regarding the evaluation process.
5. Fill in the patient’s date of birth (DOB) and age. Note the specific guidelines for patients who are 20 years or younger, especially regarding the management of abnormal Pap results.
6. Indicate the current Pap smear results by selecting the appropriate option from the provided list. Document the date of the Pap smear to maintain accurate medical records.
7. If applicable, specify any prior treatments for abnormal Pap results. Selecting 'Yes' or 'No' will determine subsequent questions.
8. If the patient is pregnant, check 'Yes' and provide the estimated due date (EDD) for better handling of their case.
9. Select the reason for the request from the options provided. Make sure to check only one box.
10. Indicate the preferred day of the week and time of day for the appointment, knowing that the request may not always be accommodated.
11. Complete the referring provider's information including their name, office number, and contact details. This ensures proper communication regarding the patient's care.
12. Answer the questions about whether the patient is aware of the referral and if notification of the appointment is desired. These details are important for patient management.
13. Once all sections are filled out, you can save any changes, download, print, or share the form based on your needs.

Complete and submit the Abnormal Pap/Colposcopy Evaluation Form online for efficient patient referral.