Referring Physician Checklist

Referring Physician Checklist

Your contact information:

• Name
• Address
• Phone number
• Fax number
• Email

Information about your patient:

• Name
• Birthdate
• Address
• Phone Number
• Social Security Number
• Insurance Information

Your patient's medical history and records:

• Medical History
• Surgeries/Procedures
• Devices: type/settings

Description of your patient's current medications:

• Type(s)
• Dosages
• Allergies

Diagnostic test reports plus actual films or tracings:

• Chest x-ray, CT scans, ultrasounds: x-ray films plus report
• Other

Other links in Pediatric Transplant site:
Transplant programs [kidney], [liver], [heart], and [lung]
Transplant Team
Information for Healthcare Professionals
Indications and Contraindications [kidney], [liver], [heart], and [lung]