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National Jewish Physician Consultation Form

Consult with a National Jewish Physician Regarding Your Patients

You can complete the Physician Consultation Form below by filling in the information, printing, and faxing it to (303) 270-2162.

If you have questions or would like to speak with someone live, you can contact the Physician Line by phone at 1-800-NJC-9555 (1-800-652-9555) from 8 am to 4:30 pm Mountain time (10 am to 6:30 pm Eastern time) Monday through Friday.

Important Notice: You must click the "Format For Printing" button at either the top or bottom of this form before printing. Printing this form before formatting can cause important information to not show on the printed page.

 

Physician Information:
Physician Name:
Specialty:
Address:
City:
State:
Zip:
Phone:
Fax:
Pager:
Best Time to Call:
E-mail Address:

Patient Information:
Patient Name:
Patient Date of Birth:
Primary Diagnosis:
Other Medical Problems:
Onset of Symptoms and Course of Illness (including complicating factors):
 
Test Results:
Medications:
Intubations:
Smoking History:
# of Hospitalizations in Last 12 Months:
 
# of ER Visits in Last 12 Months:
 
Questions for National Jewish Consulting Physician:
 


Physician Signature:		  
 
   I have read and agree to the disclaimer statement
 

© Copyright 2007 National Jewish Medical and Research Center

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