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Please complete the form below to request an appointment or RSV Prophylaxis - Synagis:
If you have a discharge summary or patient notes, please fax them to 407-898-9443.
615 E. Princeton Street, Suite 310
Orlando, Florida 32803
* = Required field
Email Address or Name (Medical Office or Sender):*
Patient Name:*
Date of Birth:*
Gestational Age:
Parent/Guardian Name:*
Parent/Guardian Phone:*
Referring Physician:*
Referring Physician Phone Number:*
Referring Physician Fax Number:
Do you want to be contacted with the appointment date when scheduled with the patient?
Yes
No
Referring Office
Select the time range that is best for patient/parent:
8:30am - 10:00am
10:00am - 11:30am
1:00pm - 2:30pm
2:30pm - 4:00pm
Patient’s Gestational Age at Birth (in weeks):
Birth Weight:
Current Weight:
Primary Diagnosis:
Select:
Congenital Heart Disease (747.0 - 745.4)
Chronic Respiratory Disease Arising in the Perinatal Period (CLD) (770.7)
Congenital Abnormality of Respiratory System (770.0 - 770.9)
≤ 24 weeks of gestation (765.21 - 765.22)
25 - 26 weeks of gestation (765.23)
27 - 28 weeks of gestation (765.24)
29 - 30 weeks of gestation (765.25)
31 - 32 weeks of gestation (765.26)
33 - 34 weeks of gestation (765.27)
35 - 36 weeks of gestation (765.28)
≥37 weeks of gestation (765.29)
Other Respiratory Conditions of Fetus and Newborn
Comments/Other Diagnosis:
Diagnosis of Chronic Pulmonary Disease (CLD/BPD) and <24 months of age?
Yes
No
Is patient receiving medical treatment of: (check all that apply and provide last date received)
Oxygen
Corticosteroids
Bronchodilator
Diuretics
Diagnosis of hemodynamically significant congenital heart disease and <24 months of age?
Yes
No
Patient has the following condition:
Diagnosis of moderate-severe pulmonary hypertension
Medications for CHD
Prematurity:
Select Gestational Age:
Gestational age of ≤28 weeks and <12 months of age at the start of the RSV season
Gestational age of 29-32 weeks and <6 months of age at the start of the RSV season
Gestational age of 32-35 weeks and <6 months of age at the start of the RSV season
Clinically has the following risk factors. *** If patient’s GA is greater than 32 weeks, at least 2 risk factors are required. *** (Check all that apply)
Live more than 30 min from hospital, urgent care or ER
Exposure to environmental air pollutants
Day Care
Severe neuromuscular disease
Crowded living conditions
Family history of asthma
School-age siblings
Other medical history
NICU History?:
Yes (if yes, please fax discharge summary)
No
Was there a NICU/HOSPITAL dose administered?
Yes
No
Date of NICU/Hospital dose, if administered:
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