Professional Imaging MBSS Consultation Referral Form

Step 2 of 8

Patient Information
Patient Name (Required)*

First NameLast Name
Patient DOB (Required)*

MonthDayYear
Date
Gender*
Primary Contact Information for Scheduling (Required) i.e. nurse, caregiver, patient*

First NameLast Name
Phone Number (Required)i.e. nurse, caregiver, patient
Primary Insurance Type
Medicare Number(MBI)
Insurance
Insurances
Insurance Name
Policy Number

Step 7 of 8

Current Treatment for Dysphagia
Current Treatment

Oral/Pharyngeal ExercisesE-StimThermal StimPending MBSS Consultation to Initiate TreatmentSwallowing/Feeding StrategiesNone at this time

Step 8 of 8

MBSS Consultation Order
Order Given by Physician/NP/PA (ONLY VERBAL ORDER REQUIRED) *

Ordering Provider First Name Ordering Provider Last Name
Only require verbal order to schedule our offices will contact to verify order in place
Verbal Order Received *
Please submit your order by email to office@proimagetx.com or fax at 281-272-6281 so we can get your patient scheduled.
Signature of Person Confirming Verbal Order with Credentials (SLP/Nurse/DOR/DON, etc. )*

Clear
Printed Name of Person Verifying Verbal Order*

First NameLast Name
Title of Person Verifying Verbal Order*
Other Title*
Order PI*

MBSS Consultation with Professional Imaging
Order MDC*

MBSS Consultation with Midwest Dysphagia

MBSS Study
Esophageal scan-approx. 30% of pts have asymptomatic esophageal dysphagia, view esophageal emptying into the stomach Vocal cord assessment-for closure to protect against aspiration Mandibular/dental assessment-for of structural integrity/abnormalities and function for chewing/muscular support to evaluate the risk for choking with solids to determine the appropriate diet level Cervical spine/soft tissue assessment-for structural integrity/abnormalities and function, changes can lead to redirection of bolus increasing risk of aspiration and requiring a different level of strategy use Frontal chest view-for aspiration when aspiration occurs, allows for risk stratification for aspiration pneumonia The physician consult requested for dysphagia-impact of PO intake on prognosis, the impact of medication and anatomy, quality of life, and rehab candidacy discussion, recommendations for further consult.I Have Consent from the Patient or Legal Guardian

Additional Documents i.e. H&P, Medication List, copy of written order (Optional)

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MBSS Consultation Referral Form