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Otolaryngology Head and Neck Surgery Request for Service  Form

Otolaryngology Head and Neck Surgery Request for Service Form

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Croup Feeding Concerns Reflux Hoarseness Nasal/Sinus Issues Recurrent Sinusitis Nasal Obstruction Rhinitis Epistaxis Nasal Trauma Neck Mass Enlarged Lymph Node Cyst Parotid Mass Thyroid Mass Pre auricular Sinus/Skin Tag Other Step 3 Info Requested for Each Referral 1 How long has the patient had the condition days/weeks/months 2 Pertinent and Quick Patient History 1 2 sentences Please Print 3 Questions referring provider wants answered by Specialist 4 Has the referring provider...
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