General Hematology and Platelet Dysfunction Clinic Consultation Form

Email address*
example@example.com
We currently conduct consults on the first Tuesday of every month, at 11:30am CST. Please select your preferred consultation date using the calendar below. If your case is urgent, please check the box for urgent cases ONLY. Do not select a date. We will review the case and reach out to the submitter.

April 7, 2026May 5, 2026June 2, 2026July 7, 2026August 4, 2026September 1, 2026October 6, 2026November 3, 2026December 1, 2026
My case is too urgent -- need to discuss soonerOther
Requestor Information
Location*
Requested by Name*

First NameLast Name
Institution*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Fax (US submitters: Please add the clinic fax where notifications will be sent)*
Please enter a valid phone number.Format: (000) 000-0000.
Patient Information
Name*

First NameMiddle NameLast Name
Date of birth*

MonthDayYear
Please enter patient's birthdate
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

MaleFemale
Ethnicity*
Diagnosis/working diagnosis only*
Date of diagnosis*
Reason for consultation-Please include a question/statement. *
Patient Medical History
Previous medical problems (including bleeding/bruising symptoms, allergies, any need for previous transfusions, description of menstrual cycles if applicable, previous surgeries)
Presenting and current signs/symptoms (including bleeding/bruising symptoms, allergies, any need for previous transfusions, description of menstrual cycles if applicable)
Please list any medications the patient is taking, including OTC and supplements.
Family Medical History
Family history (bleeding, heavy menstrual bleeding, any transfusion needs, operative history)
Diagnostic Workup

Please include all relevant information to prevent any delays.
Please enter diagnostic workup data below.

Attach all related documents. Only email information that was not available at the time of submission.
CBC x 3 (include date/s)*
Is there a history of a normal CBC?*
Bone marrow findings, if applicable (include date/s and UPLOAD THE ORIGINAL REPORT/S)*
Other (Iron studies, B12, Folate, Coombs, Iron panel, ferritin, immature platelet fraction, immunoglobulins, ANA, etc.)
Genetic testing results. Please include all pages of the original report. (Include the name of the lab and date/s, gene name, and mutation information)*
Relevant imaging studies (include date/s)
Please upload relevant diagnostic documents (pdf) or images (maximum size for an individual file is 1GB; maximum number of uploads allowed is 25)

Cancelof
Have any other outside consults been placed/other specialties following the patient (example: endocrinology, rheumatology, etc.)?
Treatment and Disease Evolution
Initial, previous, and current therapy (include date ranges)
Transfusion history (include the most recent transfusions)-please provide lifetime total transfusions
Please provide any additional necessary information
Should be Empty:

Requestor Information

Patient Information

Patient Medical History

Family Medical History

Diagnostic Workup

Please enter diagnostic workup data below.

Treatment and Disease Evolution