Physician Consult

Please complete the form below and a National Jewish Health physician will respond to your consult request as soon as possible, usually within three business days.

You may also contact our Physician Line at 1.800.652.9555, Monday - Friday, 8:00 am to 5:00 pm Mountain Time or physicianline@njhealth.org.

For mycobacterial disease consultations, complete the Mycobacterial Referral/Consult form.

Other resources: COVID-19 Testing Referral | Refer a patient | Order a test | Radiology Consult

Provider Information

Provider First Name

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Provider Last Name

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Name of requesting office or facility

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Provider Country

United States Abkhazia Afghanistan Aland Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Ascension Ashmore and Cartier Islands Australia Australian Antarctic Territory Austria Azerbaijan Bahamas, The Bahrain Baker Island Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Antarctic Territory British Indian Ocean Territory British Sovereign Base Areas British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China, People's Republic of China, Republic of (Taiwan) Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Congo, (Congo – Brazzaville) Congo, (Congo – Kinshasa) Cook Islands Coral Sea Islands Costa Rica Cote d'Ivoire (Ivory Coast) Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Islas Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Howland Island Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jarvis Island Jersey Johnston Atoll Jordan Kazakhstan Kenya Kingman Reef Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar (Burma) Nagorno-Karabakh Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Cyprus Northern Mariana Islands Norway Oman Pakistan Palau Palmyra Atoll Panama Papua New Guinea Paraguay Peru Peter I Island Philippines Pitcairn Islands Poland Portugal Pridnestrovie (Transnistria) Puerto Rico Qatar Queen Maud Land Reunion Romania Ross Dependency Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Georgia & South Sandwich Islands South Ossetia Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor-Leste (East Timor) Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Yemen Zambia Zimbabwe

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International Address

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International Phone Number

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Best time to call

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Provider Fax Number

 

Provider Email Address

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Patient Information

Patient Medical Record Number (Or a unique number we can reference when we call you to discuss this case.)

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Age

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Gender

Male Female

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Have you previously contacted National Jewish Health about this patient?

Yes No

Primary Diagnosis

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Severity

Other medical problems

Onset of symptoms and course of illness (including complicating factors)

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Related lab and imaging results

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Medications

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Smoking history

Never a Smoker Former Smoker Currently Smoking

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Questions for National Jewish Health's consulting physician

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Comments

Disclaimer

You are provided with this notice as you have requested a consultation from a member of the faculty of National Jewish Health. National Jewish Health faculty have not seen the patient referred to in your request for consultation and are relying solely and entirely upon your report of the condition of the patient and the patient's medications. If you have any questions or are in any doubt regarding the advice provided to you regarding your patient, please contact National Jewish Health for information as to how your patient may be evaluated by National Jewish Health faculty.

I have read and agree to the disclaimer statement

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