Mycobacterial Consultation Request

The Mycobacterial Consult Service at National Jewish Health helps practitioners manage drug-resistant tuberculosis and other refractory mycobacterial and respiratory infections. We cannot do emergent consults. Our physicians donate their time for this free service and will do their best to respond within seven days of receipt of the request. Learn more about the Mycobacterial Consult Service.

You may also download the form (PDF) and fax it to 303.270.2119 or call the Division of Mycobacterial & Respiratory Infections consultation coordinator at 303-398-1279.

General consults:  To better serve you, we ask that you use this form for general (non-mycobacterial) Physician Consultations.

Provider Information

 

What questions do you want answered? *
Type of Consult
Provider First Name *
Provider Last Name *
Provider Phone Number * 
Provider Fax Number  
If out of the United States, International Phone or Fax Number
Provider Email Address * 

Patient Information

Patient First Name *
Patient Last Name *
Patient Phone Number * 
Patient Date of Birth *  
Patient Age  
Patient Gender


* 
DX and brief history *
Current medications used *
Previous medications used *
X-ray/CT scan findings *
Microbiology & Other lab data
Other pertinent info/concerns

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