Advanced Lung Disease Referral Form

Advanced Lung Disease Referral Form

Submit patient and referring physician details for lung evaluation.
Date of Referral*

MonthDayYear
Date
Lung Disease Diagnosis for Referral*
If other diagnosis please specify
- Patient Full Name*
  
  First NameLast Name
- Date of Birth*
  
  MonthDayYear
  Date
- MaleFemaleOther
- Height (In)*
- Weight (lbs)*
- BMI (Body Mass Index)
- Patient Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Patient Address*
  
  Street Address
  
  Street Address Line 2
  CityState / ProvincePostal / Zip Code
- Insurance Provider*
- Insurance Policy Number*
- Oxygen Requirement Liters Per Minute (LPM)*
- Smoking History (including all forms of nicotine, gums, vaping, Marijuana)*
- Referring Physician Name*
  
  First NameLast Name
- Email*
  example@example.com
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Physician Office Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Referring Office Fax Number *
- To submit the referral, please include comprehensive and up-to-date medical documentation that supports the patient’s current clinical status and pulmonary evaluation. Required materials include:
  - a recent history and physical (H&P)
  - The most recent office visit note
  - Medication List
  - Pulmonary function tests (PFTs)
  - A six-minute walk test (6MWT)
  - Chest X‑ray (CXR) report
  - CT scan report
  - Cardiac assessment documentation—such as an echocardiography report and left and/or right heart catheterization (LHC/RHC) reports—should be provided if available.
  - Include recent laboratory results (CBC and CMP, if available)
  - Lung biopsy results, if they have been performed.
- File Upload*
  
  Cancelof
- We kindly request that the imaging be pushed to the TGH Lung Program via PowerShare, if available. If PowerShare is not an option, please mail a CD to:
  
  TGH Lung Intitute
  5 Tampa General Circle
  Suite 300 & 730
  Tampa, FL 33606
Should be Empty: