The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

ncBEeR6yVMXfP5WYb6vpdIb6mjTwIJq9AjePSxChvv9par5RdBq8fedBfIbmuszqFxoqhLVxjuj2d8sU29BmZrY9H25QoXg3aotVDTwGvEgPbsJka

IPS/ Self-Referral Form

Returning?

A A A

Please complete and submit the form below. Upon completion, you will receive an invitation to upload medical records

Request Medical Records

View equation

Initial Referral Date

M-D-Y

Patient First Name

* must provide value

Patient Last Name

* must provide value

Patient Date of Birth

* must provide value

M-D-Y

Patient Age

View equation

Patient Gender

* must provide value

Male

Female

reset

Parent/Guardian Full Name

* must provide value

Parent/Guardian Date of Birth

* must provide value

M-D-Y

Parent/Guardian Relationship to patient

* must provide value

Address

* must provide value

Expand

Where are you currently residing?

* must provide value

What is your country of origin?

* must provide value

Language Preference

* must provide value

Phone Number

* must provide value

Cord blood infusion?

* must provide value

Yes

reset

Cerebrospinal fluid (CSF) leaks, also known as Spontaneous Intracranial Hypotension?

* must provide value

Yes

reset

Brain Tumor?

* must provide value

Yes

reset

Lung Transplant?

* must provide value

Yes

reset

Primary Medical Condition/ Additional Notes

* must provide value

Expand

What is your primary medical issue?

* must provide value

Expand

Within the last 12 months, have you had an overnight stay in a healthcare facility outside the United States?

* must provide value

Yes

reset

Hospital Name

* must provide value

Expand

Hospital Country

* must provide value

Hospital City

* must provide value

Admission Date (Most Recent)

* must provide value

M-D-Y

Discharge Date (Most Recent)

* must provide value

M-D-Y

Length of hospital Stay (in days)

View equation

If you have had multiple hospital admissions within the last 12 months, please list each episode including hospital name, state/city, country as well as admission and discharge dates.

Expand

Do you have your vaccination records?

* must provide value

Yes

reset

If you are able to provide a copy of your vaccination records to the Duke team, please click the upload button (Will be scanned into your chart)

Upload file

Have you received measles vaccine?

* must provide value

Yes

reset

Have you received varicella (chicken pox) vaccine?

* must provide value

Yes

reset

After you submit this form, you will receive an email invitation to upload medical records.

* must provide value

I understand that in order to proceed with my request, I have to submit all available medical records pertinent to the primary medical issue stated above.

Financial Class

* must provide value

Department

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.