Request for eConsult

**Please ensure that a signed Authorization to Release information is completed by the patient and fax it to the eCoordinator at (319) 368-5581 along with all other supporting results/reports from your EHR/EMR.

It is critical you include all requested information below so we can ensure your consult is what you need.**

Patient Information


Gender *

Pediatric patients (<18 years of age) require parent/guardian name and phone number.


Physician Information


What is the purpose of this eConsult? (Please check all that apply and provide comments as needed) *
Primary Reason for the Request (Providers may choose all that apply) *

Supporting Clinical Information
Be specific on what you want to send to Mayo for your consult. Tell us as much about the testing and data you want sent including; performing entities/locations, dates, and if you have the information in your office Electronic Health Record or if we need to get from the performing entity. Check the applicable boxes below and identify the patient medical information pertinent to the specific question being asked for.


We need your office to fax all results/reports from your EMR that you want sent to Mayo to:
Fax: 319-368-5581
Attention: Janet Libe

Cardiac results