Get Mobile Dysphagia Consultation Order Form

Filling out the Mobile Dysphagia Consultation Order Form online can streamline the process of requesting a consultation for patients with swallowing disorders. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to complete the Mobile Dysphagia Consultation Order Form online:

1. Press the 'Get Form' button to access the Mobile Dysphagia Consultation Order Form and open it for editing.
2. Begin by entering the facility contact information in the first section. Provide the facility name, city, state, phone number, and extension. Specify the scheduling contact's name, department, and phone number, including the extension.
3. In the patient demographics section, fill in the name, date of birth (DOB), and sex of the patient.
4. In the verbal consent section, indicate whether verbal consent was obtained from the patient, or their healthcare proxy. Include details about the patient’s skilled stay status and provide any relevant insurance information.
5. Fill out the ordering physician's information, including their first and last name, and ensure the physician's order for a dysphagia consultation, including necessary assessments, is documented.
6. Check the appropriate boxes for reasons mobile or onsite visits are required, providing explanations where necessary.
7. Complete the medical history section by checking relevant diagnoses and respiratory status as applicable.
8. In the medical necessity for consult section, check all applicable symptoms and their duration and frequency.
9. Specify any current diet restrictions, treatments, and any special accommodations required for the patient.
10. Once all sections are completed, review the form for accuracy. Save any changes, then download, print, or share the form as needed.

Begin your online form completion today for efficient dysphagia consultation planning.