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Cura Consult Request
Patient Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Gender
(Required)
Male
Female
Non-Binary (X)
Unknown
Patient MRN
Specialist Needed
(Required)
Please select below
Pulmonary
Neurology
Neurosurgery
Psychiatry
Cardiology
Infectious Disease
Nephrology
Hospitalists
Facility Name/Location
(Required)
Reason For Consult
(Required)
Secure Upload or fax documents to 800-886-5985
Drop files here or
Select files
Max. file size: 32 MB.
Please include facesheet, history and physical, recent progress notes, MAR, labs, ECG (for psych and as needed), imaging reports as needed, imaging disc to separate link.
Use this link for CD image uploads
Images Uploaded
Requestor Name
Nursing Station Phone
Nurses Station Ext.
Clinical Contact Name
I am the Clinical Contact
I am the Clinical Contact
Clinical Contact Phone
Ext.
