REQUEST FORM: CONSULTATION / CASE RESEARCH SUPPORT

TO: Agromedicine/OEM Program / MUSC FAX 843-792-4702

 

FROM: ________________________________________

 

ADDRESS:

 

 

TELEPHONE: ____________________ FAX: ___________________

 

REQUEST FOR: CONSULTATION / CASE RESEARCH SUPPORT

1. Please describe the nature of your request:

 

 

2. If possible, please attach the patient's current history from the chart (patient name and address are not requested). If not, please provide the following patient information: Age: _____ Sex: _____

 

Patient Exposure History :

 

 

 

Current Signs and Symptoms:

 

 

 

Significant Medical History: