UC Davis Health System
Clinical Telehealth Program Referral Guidelines
Pediatric
Endocrinology
Clinical Telehealth Consultations
The following is a listing of clinical conditions appropriate for clinical telehealth pediatric endcrinology
consultations. If you would like to refer a patient with a condition which is not listed below, please send your
request with the patient’s chart notes to the telehealth coordinator for the specialist’s consideration.
Appointment Scheduling:
New: 40 minutes
F/U:
20 minutes
Clinical Conditions:
Hypo/Hyperthyroidism
Precocious Puberty
Pubertal Delay
Growth Delay
Hypo/Hyperparathyroid
PCOS
Necessary Clinical Information Includes:
1) Age and sex of child
2) Findings on current exam
3) Current medications and allergies
4) Height – by wall mounted stadiometer X3 (results must be
within 0.3 cm range), weight & v/s- need to be sent to be
entered on our EMR before patient seen
5) Growth charts to be shown over video before patient is
roomed
6) Hard copy of x-rays for growth delay conditions (bone, age
–left hand wrist)
Thyroid Condition:
1) Recent TSH and free T4 and free T3 (hyperthyroid only)
2) Thyroid antibodies – anti TPO, Thyroglobulin, Thyroid
stimulating immunoglobulin (hyperthyroid only)
Pubertal Conditions:
1) Pediatric FSH, LH, and pediatric testosterone or pediatric
estradiol (gender determines) and DHEAS
2) Bone Age
Level of Presenter Required:
Medical practitioner to receive
recommendations and perform physical
examinations, including genital exam with
measurement of phallic structure and
gonads
Video Equipment Required:
1. Videoconferencing unit
2. General Patient Exam Camera
Other Equipment Required:
Stadiometer used for patients with
osteoporosis
The following information must be
received prior to scheduling an
appointment:
1. Telehealth Referral Request Form
2. Necessary Clinical Information: listed on
left side
The following must be received before
the consult begins:
1. Signed UCDHS Acknowledgement of
Receipt: Notice of Privacy Practices form
(new patients only)
2. Documented verbal consent from patient
for participation in telehealth consultation
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UCDHS Clinical Telehealth Program
Toll Free: (877) 430-5332
Referral Fax: (866) 622-5944
http://healthsystem.ucdavis.edu/cht/clinic/
UC Davis Health System
Clinical Telehealth Program Referral Guidelines
Pediatric
Endocrinology
Clinical Telehealth Consultations
Growth Conditions:
1) TSH, free T4,IGF-1,IGF-BP3, CMP
2) Bone Age
Calcium Conditions:
1) Serum Calcium, albumin, phosphorous, PTH, 25 OH
Vitamin D
PCOS Conditions:
1) Pediatric Testosterone ,DHEAS,17-OHprogesterone, TSH,
free T4, fasting glucose, fasting lipids, and HbA1
Appointment Scheduling:
New: 40 minutes
F/U: 20 minutes (Diabetes—30 minutes)
Level of Presenter Required:
Medical practitioner to receive
recommendations and perform physical
examinations, including genital exam with
measurement of phallic structure and
gonads
Video Equipment Required:
1. Videoconferencing unit
2. General Patient Exam Camera
Other Equipment Required:
Stadiometer used for patients with
osteoporosis
The following information must be
received prior to scheduling an
appointment:
1. Telehealth Referral Request Form
2. Necessary Clinical Information: listed on
left side
Consultants: Abigail Fruzza, MD
Dennis Styne, MD
The following must be received before
the consult begins:
1. Signed UCDHS Acknowledgement of
Receipt: Notice of Privacy Practices
form (new patients only)
2. Documented verbal consent from
patient for participation in telehealth
consultation
UCDHS Clinical Telehealth Program
Toll Free: (877) 430-5332
Referral Fax: (866) 622-5944
http://healthsystem.ucdavis.edu/cht/clinic/