Panel Physician Consultantion Request

* Indicates required fields

Please fill in the form below. Provide as much detail in the question field to assist the consultant's understanding of the patient history and the question.

Name (first) *

(last) *

Occupation *

Setting *

Need Answer *

Email *

Primary Phone

Ext

Alt Phone

Ext

Fax

Country *

Panel Site

Other Site

City

Have you requested consultation assistance about this patient before?

Yes

Question *

Do not include patient name, DOB or other identifying information.
Do include information that is relevant to the case and the question:

History of present illness
Previous history of active TB or LTBI treatment (including treatment regimens and dates)
Past medical history (comorbid conditions)
Medications; Allergies
Physical exam
Labs (including culture and DST results, if available)
Pertinent radiographic findings

Is patient between 0-18 yrs old?

Yes

If so, is patient adoptee?

Yes

Patient citizenship status

Refugee

Immigrant

Other