Orthopedic Teleradiology Patient consent(Required) Patient gave consent for consultative services Type of Request(Required)Urgent: Medically emergentNon-Urgent: Prioritize for travelRoutine: Most commonSurgeon Requested Additional InformationEmergent Cases: A phone call to Ortho Field Support surgeon is required. M-F from 8am-5pm: Call the ANMC Ortho Field Support office at 907-729-1791. After 5pm and on weekends: Call the ANMC operator at 907-563-2662 to contact the on-call surgeon.Non-Urgent and Routine Cases: Non-urgent telerads received outside of M-F, 8am-5pm will be reviewed the next business day.Requesting Organization(Required)AISU Annette Island Service UnitAPIA Aleutian Pribilof Islands AssociationASNA Artic Slope Native AssociationBBAHC Bristol Bay Area Health CorporationCATG Council of Athabascan Tribal GovernmentsChitinaCRNA Copper River Native AssociationEAT Eastern Aleutian TribesICHC Eyak/Illanka/CordovaKANA Kodiak Area Native AssociationKarluk Tribal CouncilKIC Ketchikan Indian CommunityKIT Kenaitze Indian TribeManiilaq Health AssociationMt. Sanford Tribal ConsortiumNinilchik Traditional CouncilNSB North Slope BureauNSHC Norton Sound Health CorporationSCF South Central FoundationSEARHC Southeast Alaska Regional Health CorporationSVT Seldovia Village TribeTCC Tanana Chiefs ConferenceValdezYakutatYKHC Yukon-Kuskokwim Health CorporationIf other please specify(Required) History(Required)New Condition (Ortho has never been consulted for specific injury)Follow Up (For existing condition with previous consult)Patient InformationPatient First Name(Required) Patient Last Name(Required) Patient Date of Birth(Required) Month Day Year ANMC Chart Number Patient Email Patient Phone Number HiddenPatient First Name HiddenPatient Last Name HiddenANMC Chart Number HiddenPatient DOB MM slash DD slash YYYY Clinical HistoryInclude specific question for consulting orthopedic surgeon and adequate detail to assist in making medical decisions.Date of Injury(Required) Month Day Year Date of Exam/X-ray(Required) Month Day Year Mechanism of injury and/or pertinent history(Required)HiddenPatient First Name HiddenPatient Last Name HiddenANMC Chart Number HiddenPatient DOB MM slash DD slash YYYY Clinical ExamAll exam fields below are required or enter N/A.Specific Body Part(s) Involved(Required) Laterality(Required)LeftRightBi-lateralNeuro Status/Exam(Required)Within Normal Limits/NASee detailsNeuro Status/Exam Details(Required) Vascular/Perfusion(Required)Within Normal Limits/NASee detailsVascular/Perfusion Details(Required) ROM(Required)Within Normal Limits/NASee detailsROM Details(Required) Wound/Incision Status(Required)Within Normal Limits/NASee detailsWound/Incision Status Details(Required) Point of Tenderness (Specify Location)(Required)Within Normal Limits/NASee detailsPoint Tenderness Details(Required) Mechanism of Injury/Other Exam DetailsPatient has an ANMC chartYesNoIf patient does not have an ANMC chart, please upload the demographic form using the file upload field belowOptional Document Upload (JPG, PNG, PDF) Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 50 MB, Max. files: 10. HiddenPatient First Name HiddenPatient Last Name HiddenANMC Chart Number HiddenPatient DOB MM slash DD slash YYYY Provider InformationComplete information is required for ALL submissionsReferring Provider Name(Required) Credentials(Required)RNPAMDDONPCase ManagerCHA/CHAPProvider NPI Number (DO NOT SKIP)(Required) Please enter 10 digit Provider NPIProvider's Organizational Email(Required) This email will be used to confirm the receipt of submission.HiddenProvider's Organizational Email This email address will be used to confirm the receipt of submission.Direct Phone Number (Preferred)(Required) Hospital/Department Phone Number(Required) Additional Contact Information (check all that apply) Do you want results sent to an additional provider? Are you completing this form on behalf of the provider? Additional Provider Name Additional Provider Phone Submitter Name Submitter Phone Submitter information will be used only if needed by Ortho rep for clarification purposes.HiddenPatient First Name HiddenPatient Last Name HiddenANMC Chart Number HiddenPatient DOB MM slash DD slash YYYY
