Mayo Clinic eConsult Physician Request Form at Middlesex Health

All fields are required unless otherwise noted.

Provider Information
Provider info will be stored on this computer.
Name is required.
A valid email address is required.
A confirmation email will be sent to this email address.
A valid Phone number is required.
A valid Fax number is required.

Clinical Information
Diagnosis is required.
Primary Reason for Request (pick one or more options)
Primary reason for request is required.
'Other' primary reason for request description is required.
Reason for eConsult request is required.
Please be specific and concise.
Details about your question is required.
Requested Mayo clinic department is required.

Patient Information
First name is required.
Last name is required.
City is required.
A valid date of birth is required.
mm/dd/yyyy
Gender
Gender is required.

Patient Documentation
I Will Submit the Most Recent Office Note
You must agree to submit the most recent office note.
Please select the relevant patient information you will be sending with the eConsult.
Operative/Procedure Report(s)?
You must select Yes or No for "Operative/Procedure Report(s)".
Surgery date is required if including an operative/procedure report.
Surgery type is required if including an operative/procedure report.
Relevant Lab Results Included?
You must select Yes or No for "Relevant Lab Results".
Lab date is required if including relevant lab results.
Lab type is required if including relevant lab results.
Relevant Imaging Results?
You must select Yes or No for "Relevant Imaging Results".
Imaging date is required if including relevant imaging results.
Imaging type is required if including relevant imaging results.
e.g. CT / MRI / Cardiology

Indicate if Pathology Needs to Be Sent with E-Consult
Relevant pathology submitted to Mayo?
You must select Yes or No for "Relevant pathology submitted to Mayo".
Path date is required if submitting relevant pathology.
Path type is required if submitting relevant pathology.
e.g. Lymph Nodes, Prostate
"Lab Pathology Performed at" is required if submitting relevant pathology.

Additional Information

Security Verification
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