Download Amyloid Referral

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The documents and information contained in the facsimile are confidential material and may be legally privileged. The materials
are intended only for the use of the individuals or entity addressed. If you are not the intended recipient, do not use or disclose
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Patient:
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Consult Date:
REQUIRED RECORDS FOR NEW PATIENT REFERRAL: Amyloidosis
MD PROGRESS NOTES:
Initial Consultation with Oncologist
Most Recent Progress Note
PATHOLOGY REPORTS--AT DIAGNOSIS AND MOST RECENT:
All Bone Marrow Biopsy and Aspirate Reports
include any special studies performed: flow cytometry, cytogenetics
Other Biopsy Reports, if applicable
such as biopsy of heart, kidney
LABS AT DIAGNOSIS AND MOST RECENT:
CBC
Chemistry panel, LDH
Immunoglobulin panel (IgG, IgA, IgM)
Beta-2 microglobulin
C-Reactive Protein, if available
SPEP (serum protein electrophoresis), SIEP (serum immunoelectrophoresis) and/or Immunofixation
Urine for TP (total protein)
UPEP (urine protein electrophoresis), UIPEP (urine immunoelectrophoresis) and/or Immunofixation
RADIOLOGY, NUCLEAR MEDICINE, AND OTHER REPORTS AT DIAGNOSIS AND MOST RECENT:
Chest X-ray
EKG
Bone Scan
MUGA Scan
TREATMENT RECORDS / FLOWSHEETS
For all chemotherapy cycles or other injections/infusions
The documents and information contained in the facsimile are confidential material and may be legally privileged. The materials
are intended only for the use of the individuals or entity addressed. If you are not the intended recipient, do not use or disclose
this facsimile. If you have received this facsimile in error please immediately notify us by telephone same.