Get Fetal Echo Request Form

This guide provides clear, step-by-step instructions on how to accurately complete the Fetal Echo Request Form online. By following these guidelines, you can ensure that all necessary information is submitted correctly for a smooth consultation process.

Follow the steps to successfully complete your Fetal Echo Request Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date of referral in the format mm/dd/yyyy. This is an essential field that helps document when the referral was made.
3. Provide the diagnostic information by filling in the patient's name. Input the last name followed by the first name in the designated fields.
4. Enter the patient's date of birth in the format mm/dd/yyyy to ensure proper identification.
5. Fill in the date of the most recent ultrasound results in the appropriate section (mm/dd/yyyy). This information is critical for the medical review.
6. Complete the patient contact information section. Include their address, home phone number, and mobile number.
7. Identify the primary or referring OB by entering their name and phone information. This helps facilitate communication between medical professionals.
8. Indicate the obstetrical history by filling out G, P, TAB, and SAB. Additionally, note the last menstrual period (LMP) and estimated due date (EDC) in mm/dd/yyyy format.
9. Document the gestational age today in weeks and days, as this detail is crucial for assessing the case.
10. Specify the indication for referral, including increased nuchal translucency (NT) measurement, family history, or any known conditions.
11. If applicable, fill out the insurance preauthorization section for any necessary insurance confirmations prior to scheduling.
12. If the patient needs additional fetal treatment services, list those under additional fetal treatment indications and provide any relevant comments.
13. Finally, complete the staff only section by entering the date scheduled for the fetal echo and gestation at scheduled echo details.
14. Once you have filled in all necessary fields, review the information for accuracy. You can then save changes, download, print, or share the form as needed.

Complete your Fetal Echo Request Form online today for timely and effective medical consultation.