Date eConsult Request
Received:
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FedEx Date:
Type/Study:
Office Coordinator:
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FedEx Routing #: Click here to enter text.
Date eConsult Submitted to
Central Coordinator: Click here to enter a date
Address: Mayo Medical Laboratories
Attention: Pathology
3050 Superior Drive NW
Rochester, MN 55901-1995
Images Uploaded (Date): Click here to enter a date.
Encryption Code: Click here to enter text.
Date eConsult Request
Received from Office: Click here to enter a date
Central Coordinator:
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Provider Name and Direct Contact Number
(MD, DO)
:
Office Address:
Date eConsult
Submitted to Mayo:
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Patient Name
Patient Address:
Date Received from
Mayo:
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(Last, First, Middle Initial)
:
Office Phone:
Office Fax: Medical Record Number:
List of Consultants / Care Providers:
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Patient Phone Number:
Patient D.O.B.:
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Do you have an Informed Consent Signed by the Patient?
Patient Gender:
Yes No
What Specialty would you like to review this case?
Please limit documents to 25 pages.
1.
Diagnosis:
2. Reason for eConsult (Please word as a specific question for Mayo Clinic Provider):
3. Choose Primary Reason(s) for the Request Yes No
A. Is the current assessment and/or approach correct?
B. What other/ongoing diagnostics should be considered?
C. Should other treatment/management options be considered?
D. Should the patient be seen at Mayo Clinic?
E. Is the patient a candidate for a research study?
F. Other, please indicate in detail about your question.
4. Provide documentation of the patient’s relevant:

A.
Clinical Summary:
B.
History & Physical, including: a.
Family History of Neurological Disease (be specific) b.
Diagnosis (Include approximate date of symptom onset) c.
Current and Past Medical Treatment d.
Current Medications
C.
Neurology Work-up to Date, Include the Most Recent: a.
Biopsy b.
Cerebral Spinal Fluid Analysis c.
Electroencephalography (EEG) d.
Electromyography (EMG) e.
Labs (i.e., LP, etc.) f.
Invasive Neuro Procedures (List): g.
Neuro Imaging, i.e. CT/MR, PET (List):
D.
Cerebrovascular Work-up to Date, Include the Most Recent: a.
Images: CT, MRI, Neurovascular Imaging b.
Labs: (i.e., hyper coagulate work-up, inflammatory markers) c.
Biopsy
E.
Cardiac Work-up (i.e., ECHO, TEE, cardiac monitoring)
F.
Epilepsy Work-up to Date, Include the Most Resent: a.
Epilepsy monitoring unit evaluation b.
Epilepsy interictal PET scan c.
Neuropsychological testing d.
CSF results
G.
If Hospitalized, Summary of Most Recent Hospitalization
4. Are there any details that the patient is unable or unwilling to provide?
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