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SYNAGIS REFERRAL FORM 2021-2022
**FAX COMPLETED FORM TO SYNAGIS REFERRAL PROGRAM at 585-276-2664**
BABYS NAME:________________________________DATE OF BIRTH:______________
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REF E R R I N G P H Y S I C I A N : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ P H O N E : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
( 1 . ) P r e m a t u r i t y
P a t i e n t s G e s t a t i o n a l A g e : _ _ _ _ _ _ _ w k s _ _ _ _ _ _ d a y s B i r t h W e i g h t : _ _ _ _ _ _ _ _ _ _ _ _
C u r r e n t W e i g h t _ _ _ _ _ _ _ _ _ _ _ k g l b s ( c i r c l e o n e ) D a t e R e c o r d e d _ _ _ _ _ _ _ _ _ _
ۉ G e s t a t i o n a l a g e o f d"2 8 6 / 7 w e e k s a n d < 1 2 m o n t h s o f a g e a t t h e s t a r t o f R S V s e a s o n
( D O B D e c e m b e r 1 , 2 0 2 0 o r l a t e r )
ۉ G e s t a t i o n a l a g e o f 2 9 0 / 7 - 3 1 6 / 7 w e e k s , < 1 2 m o n t h s o f a g e a t t h e s t a r t o f R S V s e a s o n
( D O B D e c e m b e r 1 , 2 0 2 0 o r l a t e r ) w i t h a r e q u i r e m e n t f o r > 2 1 % o x y g e n f o r a t l e a s t t h e f i r s t 2 8 d a y s a f t e r b i r t h
N I C U H I S T O R Y : ۉ Y e s ۉ N o
W a s t h e r e a N I C U / H O S P I T A L d o s e a d m i n i s t e r e d ? ۉ Y e s ; d a t e a d m i n i s t e r e d : _ _ _ _ _ _ _ _ _ ۉ N o
( 2 . ) D i a g n o s i s o f c h r o n i c p u l m o n a r y d i s e a s e ( C L D / B P D ) , g e s t a t i o n a l a g e o f
3 1 6 / 7 w e e k s o r l e s s , a c t i v e t h e r a p y 6 m o n t h s b e f o r e t h e s t a r t o f t h e R S V s e a s o n ( 6 / 2 0 2 1 o r l a t e r ) a n d D O B 1 2 / 1 / 2 0 1 9 o r l a t e r
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d a t e r e c e i v e d ) :
ۉ O x y g e n D a t e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
ۉ D i u r e t i c s D a t e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
ۉ C o r t i c o s t e r o i d s D a t e : _ _ _ _ _ _ _ _ _ _ _
( 3 a ) D i a g n o s i s o f c o m p l e x c o n g e n i t a l h e a r t d i s e a s e a n d / o r c y a n o t i c h e a r t d i s e a s e w i t h D O B 1 2 / 1 / 2 0 2 0 o r l a t e r ( f i r s t y e a r o n l y )
ۉ Y e s I n d i c a t e t y p e o f h e a r t p r o b l e m a n d I C D - 9 d i a g n o s i s c o d e :
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
ۉ D i a g n o s i s o f m o d e r a t e - s e v e r e p u l m o n a r y h y p e r t e n s i o n m ۉ D i a g n o s i s o f c o n g e s t i v e h e a r t f a i l u r e
C a r d i a c m e d i c a t i o n s : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e l a s t r e c e i v e d : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
P e d s C a r d i o l o g y O n l y - p l e a s e i n d i c a t e M D o r N P r e f e r r i n g : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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