Become a Patient

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:

Phone Number:
FAX Number:

Patient Information:

Date of Birth:
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.

© Copyright 2007 National Jewish Medical and Research Center

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Why call LUNG LINE?
Nurses can:

Answer medical questions, but not diagnose specific conditions

Provide the latest information about current treatments and healthcare topics

Send out educational materials

Answer questions about National Jewish Programs and how to become a patient

Contact LUNG LINE:
1-800-222-LUNG (5864)
or e-mail us