Online Referral Form: Lung Transplant

Now Taking Physician Referrals

We accept referrals over the phone at 801-585-3697. Our Lung Transplant Team will help facilitate the initial appointment.

Lung Transplant Assistant

Phone: 801-585-3697
Toll-free: 800-456-8341
Fax: 801-213-3969

Patient Information Needed on Referral

The following information, if available, will be requested at the time of referral:

Patient demographics, including current insurance information
Medical records from all attending physicians and specialists
History and physical
Lab work
Radiology reports
Pathology report, including lung biopsy if available
Surgery and procedure reports
Recent pulmonary function tests

Lung Transplant Evaluation Testing

The following tests are part of the evaluation process, and arranging as many of them as possible at the time you refer your patient will speed the transplant evaluation process considerably. If you have any questions regarding these tests or would like to discuss appropriate timing of these tests, please do not hesitate to reach out to our team.

Right and left heart catheterization
Colonoscopy
Echocardiogram with bubble study
DEXA scan
CT chest without contrast, PA/LAT chest X-ray
Mammogram, if a woman over 40
Pap/pelvic exam
Up to date yearly visit with dentist and ophthalmologist
Breathing tests, including spirometry, DLCO, plethysmography, and a six minute walk test

Patient Information

Patient Name

First Name

Last Name

Patient Address

Address

City/Town

State/Province

ZIP/Postal Code

Gender

Male

Female

Prefer Not to Answer

��ٳ��…

Please Specify How the Patient Identifies

Date of Birth ^*

Race/Ethnicity ^*

SSN ^*

Patient Home Phone

Patient Cell Phone

Patient Email

Marital Status

Height, Weight

Smoking cessation data, if applicable (6 months nicotine abstinence required)

Employment Status

Disabled

Retired

Unemployed

Employed

Name and Address of Employer

Patient Diagnosis

Emergency Contact

Emergency Contact Name ^*

Relationship to Patient ^*

Phone Number ^*

Referring Physician Information

Referring Physician Name ^*

Address ^*

Phone Number ^*

Fax Number ^*

Office Contact Name ^*

Primary Care Physician Information

Physician Name ^*

Street Address ^*

City ^*

State ^*

Physician Phone Number ^*

Physician Fax Number ^*

Primary Insurance Information

Primary Insurance Name ^*

Phone Number ^*

If Medicare, effective after date

Policy Number ^*

Group Number ^*

Policy Holder's Name ^*

If not self, provide Policy Holder's name, DOB, SSN, Employer, and Employer Address

Secondary Insurance Information

Secondary Insurance Name

Phone Number

Policy Number

Group Number

Call 801-585-3697 OR

91�鶹����ֱ��