Mycobacterial Consultation Form

Note: We cannot do emergent consults. Our Physicians donate their time for this free service. There may be a 1-2 week delay on answers. Please take this into consideration.

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.

Please complete the form below, print out, and fax it to: (303) 270-2119 or
(303) 270-2204 (24 hours/day).

Physician Information:

Consultation only

Patient to be seen by National Jewish

Name:

Phone Number:

FAX Number:

Patient Information:

Name:

Phone:

Age:

Ethnicity:

Date of Birth:

Sex:

Male

Female

DX and Brief History:

Current Medications:

Previous Medications Used:

X-Ray/CT Scan Findings:

What questions do you want answered?

Lab Data/Information: (E.G. cultures/susceptibility) Attach Reports only if you are referring as a patient

Other Pertinent Info/concerns or Attach Brief Summary of case if you are referring as a patient

Note: This information is provided to you as an educational service of National Jewish. It is not meant to be a substitute for consulting with your own physician.

More About:
Department of Medicine

Questions?

Mycobacterial Consultation Form

Physician Information:

Patient Information:

I Want To:

For Clinical Trial Patients:

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You are here:

More About:Department of Medicine

Questions?

Mycobacterial Consultation Form

Physician Information:

Patient Information:

I Want To:

For Clinical Trial Patients:

Sign Up for Health-E-News

LUNG LINE

More About:
Department of Medicine