Physician Consultation Request

Please complete the form below and a National Jewish Health physician will respond to your consult request as soon as possible, usually within three business days.

You may also contact our Physician Line at 1.800.652.9555, Monday - Friday, 8:00 am to 5:00 pm Mountain Time or

For mycobacterial disease consultations, complete the Mycobacterial Referral/Consult form.

Other resources: Refer a patient | Order a test | Mycobacterial Referral/Consult

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 Fax Number
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 *
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 *

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 * 

PLEASE NOTE:  Our system does not accept attachments.  If you attempt to attach a document, the information will not be processed.

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