Get Request Form For Implantable Cardioverter Defibrillator. - Providence ...

This guide is designed to help you accurately fill out the request form for an implantable cardioverter defibrillator. It provides detailed guidance on each section of the form to ensure that all necessary information is included for processing.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the request form and open it in your preferred document editor.
2. Begin filling out the patient's name in the designated field, using the format of last name followed by first name.
3. Enter the referring medical doctor’s name and the inpatient or outpatient status of the patient.
4. Provide the patient's date of birth and their complete address, including city and postal code.
5. Indicate a contact number for the patient, along with the referring physician's contact information.
6. Select the urgency of the referral from the options available, depending on the patient’s condition.
7. Fill in the specific physician's name if you want to request them, which can affect wait times.
8. Complete the indications for procedure requested and the main clinical status by marking the appropriate options.
9. Check any applicable medical history and details regarding previous implants, including dates and reasons, if applicable.
10. Indicate if any anticoagulation or anti-platelet medications are being used by the patient.
11. Fill out additional medical indicators such as NYHA class, CHADS score, and any relevant testing information.
12. Finalise the document by signing and dating the form where indicated at the bottom.
13. After completing the form, save your changes, and download or print a copy for your records, or share it as required.

Complete your request form online today to ensure timely processing.