Fillable Printable Medical Record Consultation Sheet

Medical Record Consultation Sheet

AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD

CONSULTATION SHEET

REQUEST

TO:

FROM: (Requesting physician or activity) DATE OF REQUEST

REASON FOR REQUEST (Complaints and findings)

PROVISIONAL DIAGNOSIS

DOCTOR'S SIGNATURE

APPROVED

PLACE OF CONSULTATION

BEDSIDE ON CALL

ROUTINE

72 HOURS

TODAY

EMERGENCY

CONSULTATION REPORT

RECORDS REVIEWED YES NO PATIENT EXAMINED YES NO TELEMEDICINE NOYES

(Continue on reverse side)

SIGNATURE AND TITLE DATE

HOSPITAL OR MEDICAL FACILITY

RECORDS MAINTAINED AT

DEPARTMENT/ SERVICE OF PATIENT

RELATION TO SPONSOR

SPONSOR'S NAME (Last, first, middle)

SPONSOR'S ID NUMBER (SSN or Other)

PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first middle; ID no. (SSN

or other); Sex; Date of Birth; Rank/Grade)

CONSULTATION SHEET

Medical Record

STANDARD FORM 513 (REV. 4-98)

Prescribed by GSA/ICMR (41 CFR) 101-11.203(b)(10)