Get Request Form For Capsule Endoscopy - Wake Forest Baptist - Wakehealth

Filling out the request form for capsule endoscopy is a straightforward process that facilitates timely gastrointestinal assessments. This guide aims to provide a detailed, user-friendly approach to help you navigate the online form effectively.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the document and open it for editing.
2. Enter the patient's name in the designated field. Ensure that the full name is provided as it appears on official documents.
3. Input the patient's birth date. Use the format MM/DD/YYYY to minimize errors.
4. Fill out the work phone, home phone, and cell phone fields with the appropriate contact numbers. Make sure these phone numbers are valid and checked for accuracy.
5. Provide the name of the requesting physician. This should be the full name of the medical professional initiating the request.
6. The requesting physician must sign the form in the designated area. This can often be done electronically if the form allows.
7. Enter the date of the request. Use the current date or the date when the form is being filled out.
8. Complete the office address and office phone fields. Ensure all details are precise and reflect the physician's office information.
9. Indicate whether the patient has insurance by selecting 'Yes' or 'No.' If 'Yes,' attach a copy of both sides of the insurance card to the fax or provide it as an attachment digitally.
10. If insurance is marked 'No,' note that the patient may be scheduled pending financial counseling.
11. Select the type of capsule endoscopy required by checking either 'Esophageal Capsule Endoscopy' or 'Small Bowel Capsule Endoscopy.'
12. Provide the indications for the procedure as detailed in the form. Mark the relevant options that apply to the patient's condition.
13. If required, check any previous procedures the patient has had, such as EGD, colonoscopy, etc. This helps in assessing the patient's medical history.
14. Review the contraindications listed and confirm none of them apply to the patient before submitting the request.
15. Finally, save your changes to the form, download a copy for your records, and print it if necessary. Ensure that you fax the completed form to (336) 713-7322 as indicated.

Complete the REQUEST FORM FOR CAPSULE ENDOSCOPY online today to ensure timely patient care.