Follow the steps to complete the online referral form effectively.

1. Press the ‘Get Form’ button to obtain the referral form and open it for completion.
2. Begin by entering the patient’s name and the date of the request in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the patient’s address, including the city, state, and zip code. This data helps in patient communication and record-keeping.
4. Input the patient’s date of birth and telephone numbers. Include both home and work/cell numbers to ensure effective contact.
5. Specify the date for the next appointment due, allowing the clinic to schedule necessary follow-ups.
6. Indicate the reason for long-term anticoagulation therapy by checking the appropriate diagnosis box (e.g., AFib, DVT, PE, CVA, Mechanical Valve) and if there are any other relevant diagnoses, please list them.
7. Provide the start date and the current dose. Be sure to include whether it is a trade or generic medication.
8. Indicate the expected duration of the anticoagulation therapy, specifying if it is lifelong, a set number of months, or another duration. Clearly state any additional requirements if applicable.
9. Set the INR goal by selecting from the predefined ranges or specify a different goal along with the reason for an alternate target.
10. List all medications currently taken by the patient, attaching a separate sheet if necessary to ensure clarity and completeness.
11. Review the physician notes and the patient care plan per Pharmacy and Therapeutics Protocol as you fill out the form; ensure understanding of the recommendations and procedures outlined.
12. Provide your printed name, phone number, and signature at the bottom of the form. Ensure that your authorization for monitoring and adjustment of anticoagulation therapy is clearly indicated.
13. Once all sections are complete, save the changes to the document, and prepare to download or print the form for sharing with the relevant clinics or resources.

Complete your referral forms online for efficient patient management today.