FEES Referral Request
Hi! Thank you so much for referring your patient. We look forward to helping you.
Before you complete this referral, does your facility have an established contract with us? That's a must! If you're unsure, ask your administrator or shoot me an email at
hello@louisianadysphagia.com
.
Also, this is a HIPAA compliant form, so it's safe to submit your referral through here.
Pro Tip: Get the signed physician's order for the FEES exam ASAP!
Facility
Patient's Name
First Name
Last Name
Patient's DOB
-
Month
-
Day
Year
Date
Patient's Room Number
Has the facility obtained a signed physician's order for the FEES exam and have a copy ready for the endoscopist?
YES
NO
Is there a power of attorney, and if so, who has power of attorney? In thinking about who might be present when we arrive, which loved ones do or do not have consent to the client's medical information. We ask because some loved ones want to watch the procedure and know the results.
Relevant Medical History
Check all that apply:
NPO
eating orally
drinking orally
ice chips only for therapy
free water protocol
PO in therapy only
thin liquids unlimited
thin liquids in therapy only
nectar thick liquids unlimited
nectar thick liquids in therapy only
honey thick liquids unlimited
honey thick liquids in therapy only
solids are liquidised unlimited
solids are liquidised for therapy only
solids are pureed unlimited
solids are pureed for therapy only
solids are minced and moist unlimited
solids are minced and moist for therapy only
solids are soft and bite sized unlimited
solids are soft and bite sized for therapy only
solids are easy to chew or regular unlimited
solids are easy to chew or regular for therapy only
patient prefers straw
patient prefers cup drinking
patient self feeds
patient requires help feeding
patient instructed to use small sips
patient instructed to alternate sips and bites
patient instructed to use regular size sips
patient drinks by spoon
patient uses head turn to right
patient uses head turn to left
patient uses chin tuck
patient uses head tilt to right
patient uses head tilt to left
patient uses special utensils
patient compliant on strategies and consistencies
patient not compliant
Any other details or relevant information about patient's swallow or therapy?
Your Name
First Name
Last Name
Your Position at the Facility
Best Number for Us to Call or Text You
Please enter a valid phone number.
If you're not the SLP, please indicate SLP's name and number.
First Name
Last Name
SLP's Phone Number
Please enter a valid phone number.
Submit
Should be Empty: