Physician Consultation Request

Note: Do not submit Mycobacterial Disease consultations requests using this form.  Instead, please complete the Mycobacterial Diseases Consult Service form.

 

A National Jewish Health physician will respond to your consult request as soon as possible, usually winthin three business days.

 

If you have questions, or if you would like to speak with someone, you can call the Physician Line at: 1.800.652.9555 from 8 a.m to 5 p.m. Mountain Time, Monday through Friday.

 

Other resources:  Refer a patient  |  Order a test

 

 

Provider Information
Provider First Name *
Provider Last Name *
Name of requesting office or facility *
Provider Country * 
International Address *
International Phone Number *
Best time to call *
Provider Email Address * 
Provider Information
Patient Medical Record Number (Or a unique number we can reference when we call you to discuss this case.) *
Age * 
Gender * 
Have you previously contacted National Jewish Health about this patient?
Primary Diagnosis *
Severity
Other medical problems
Onset of symptoms and course of illness (including complicating factors) *
Related lab and imaging results *
Medications *
Smoking history
Questions for National Jewish Health's consulting physician *
Comments
Disclaimer

You are provided with this notice as you have requested a consultation from a member of the faculty of National Jewish Health. National Jewish Health faculty have not seen the patient referred to in your request for consultation and are relying solely and entirely upon your report of the condition of the patient and the patient's medications. If you have any questions or are in any doubt regarding the advice provided to you regarding your patient, please contact National Jewish Health for information as to how your patient may be evaluated by National Jewish Health faculty.
I have read and agree to the disclaimer statement * 

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