eConsult Physician Request Form

Provider Information

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Clinical Information

Primary Reason for Request
(pick one or more options) *

Please be specific and concise.

Patient Information

Gender

Patient Documentation. Email to mayodocs@midhosp.org or fax to (860) 358-2035

I Will Submit the Most Recent Office Note *

Please select the relevant patient information you will be sending with the eConsult.

Operative/Procedure Report(s)?

Relevant Lab Results Included?

Relevant Imaging Results?

e.g. CT / MRI / Cardiology

Indicate if Pathology Needs to Be Sent with E-Consult

Relevant pathology submitted to Mayo?

e.g. Lymph Nodes, Prostate

Additional Information
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