Get Chla Consultation Form - The Sanger Lab - Sangerlab

Completing the CHLA Consultation Form for the Sanger Lab is an important step in accessing neurology consultation services. This guide will provide clear, step-by-step instructions to help you accurately fill out the form online and ensure that your information is properly submitted.

Follow the steps to effectively complete the consultation form

1. Press the ‘Get Form’ button to obtain the CHLA Consultation Form and open it for editing.
2. Fill in the date at the top of the form to indicate when the application is being submitted.
3. Provide the patient's name and date of birth. Please ensure that this information is printed or written clearly.
4. Enter the name of the primary medical doctor and their contact details, including phone and fax numbers.
5. If applicable, include the name of the referring medical doctor, if different from the primary doctor.
6. Specify the reason for consultation in detail. If the consultation relates to seizures, include information about the onset, whether they are febrile or afebrile, and the current frequency and type.
7. Select any relevant checkboxes that apply to the consultation, such as 'Febrile Seizure Only' or 'EEG Needed'. Include details on any medications the child is currently taking.
8. If an EEG has been conducted previously, mention this and ensure to attach the report.
9. Describe the child’s development and any other neurological conditions in detail.
10. Provide relevant past medical history and current medications being administered to the patient.
11. Fill in the parent's name and any additional contact person's name, along with their day and night phone numbers.
12. Include insurance information along with the authorization number and Medi-Cal number if applicable.
13. Review the entire form to ensure that all fields are filled out clearly and legibly. Illegible forms cannot be processed.
14. Once all the information is complete, you can save your changes, download the form, print it out, or share it as needed.

Begin filling out the CHLA Consultation Form online to ensure you have all necessary details for your consultation.