IPITTR Consultation Request

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Center Information

Institution name: This information is required.

Contact person: This information is required.

Contact’s email address: This information is required.

If this is your first consult request, please provide the following additional contact information for our records.

Contact’s title: For example: MD, PhD, RN.

Contact’s position:

Contact’s mailing address: Include street, city, state and ZIP code, or country and postal code.

Contact’s phone:

Contact’s fax:

Patient Information

Patient’s name:

Patient’s age:

Patient’s date of birth: This information is required.
Format: MM-DD-YYYY

Patient’s sex:

Male
Female
unknown

Patient’s race:

Patient is diabetic:

Yes
No
unknown

Patient has CAD:

Yes
No
unknown

Patient on dialysis:

Dialysis started: Format: MM-DD-YYYY

Other relevent health issues: For example: HTN

Consult Information

Consult questions: This information is required.

How soon is a response needed?

Standard (within 7 days)
Immediate (within 24 hours)

Please note that only consult requests involving an overwhelming medical necessity requiring immediate intervention will be considered for “Immediate” review. All other consultation requests will be handled as “Standard”.

Cancer Information

Date of diagnosis: Format: MM-DD-YYYY

Tumor classification:

Pre-existing
De novo
Donor-related
Unknown

Site(s):

Histology:

Staging:

Surgical pathology report: Include conclusions and impressions.

Treatment Information

Surgical procedure(s):

Chemotherapy: Indicate agents and when therapy was started and completed.

Radiation: Indicate type of treatment.

Other treatments:

Include follow-up since treatment.

CT / MRI / X ray:

Labs:

Oncology:

Transplant Information

Date of transplantation: Format: MM-DD-YYYY

Transplanted organ(s):

Lung
Heart
Liver
Kidney
Intestine
Pancreas

Check all that apply.

Disease requiring transplantation:

Donor type:

Living
Cadaveric
unknown

HLA match: 0–6 antigens

Patient’s MELD score:

Ascites requiring paracentesis:

Yes
No
unknown

Patient has encephalopathy:

Yes
No
unknown

Additional information: Include additional information related to transplantation, such as multiple transplants.

Induction Therapy

Induction therapy: List all received to date.

Rejection History

Rejection history: List all rejections and treatments.

Immunosuppression Therapy

Calcineurin inhibitors: For example: Cyclosporine, Tacrolimus.

Antiproliferatives: For example: Azathioprine, MMF.

Steroids:

Other immunosuppressives:

Additional Information

Additional information: Include any information you believe will be helpful to us in consulting on your patient.

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