Patheous Health Patient Swallow Study Referral (2)

Patheous Health FEES Referral

Facility*

Street Address*

Address Line 2

City

State/Region/Province

Postal / Zip Code

Your Name or Our Contact at the Facility for the Study *

Title *

First Name *

Last Name *

Mobile Phone Number for Appointment Confirmations and Updates By providing your mobile number you are agreeing to receive SMS messages from our scheduling team regarding your FEES appointment. If you do not wish to be contacted via SMS please provide a work email below.

Email for Scheduling

Are you point of contact?

Point of contact

Title *

First Name *

Last Name *

Email for Scheduling

Patient Detail *

Patient First Name *

Patient Last Name *

Patient Room Number *

Patient Date of Birth *

Patient's Sex *

If your patient is currently covid positive please select the date of diagnosis. **We are still scheduling out 10 days from covid positive date. If your patient tests negative prior to the date we provide you please let us know and we will do our best to move that appointment up!

Has your patient had a swallow study with us before?

Yes

If you are unsure please mark yes. This will allow us to look for the previous report.
Does your patient have any contraindications for a swallow study?

Recent facial fractures (contraindication for FEES)

Total laryngectomy

Is there any other information you would like to share about your patient?

Does your patient have any days or times when they are not available?

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