Finnegan Health Services

Urological Prescription Form

Submit referrer, clinic, patient, catheter, and referring source details for urological prescription intake.

Referrer

Referrer Name

Facility/City

Phone Number

Clinic

Physician's Name

Clinic/City

Phone Number

Patient Information

Patient's First Name

Patient's Last Name

Date of Birth

Gender

Male Female

Phone Number

Email Address

Emergency Contact

Emergency Contact Phone Number

Relationship to Patient

Medicaid #

Medicare #

Discharge Date

Diagnoses

Insurance Company

Insurance Phone Number

Policy #

Group Number

Catheter Details

Catheter Type

Intermittent/"In and Out" Foley

Does patient need automatic shipment?

Yes No

How often are catheters needed?

Tip Type

Balloon Size

French Size

Length

Lubricant

Yes No

Estimated Duration of Need

Frequency of Catheterization — how many times per day/month?

Special Requirements

Other Items

Male External Catheter Size

Bedside Drainage Bag

Yes No

Urinary Drainage Bag

Yes No

Other

Referring Source

Referring Source Clinic

Referring Source Name

Referring Source Phone

Referring Source Email or Fax