In-Home Phototherapy Order Form

We appreciate your continued confidence in The Perfect Push.

For the most seamless experience, please submit referrals before 4 p.m.

For referrals placed after 4 p.m., please call the office to confirm availability and prioritize same-day support whenever possible.

Outpatient Phototherapy/Bilirubin

Order Form

Phone Number : 945.218.5688

Fax Number : 833.FAX.TPP1 (833.329.8771)

Email : referrals@theperfectpush.com

Mother's Name

Mother's Date of Birth

Infant Name

Sex

Infant Date of Birth

Time of Birth

Time

HoursMinutes

Address

Phone

Infant Weight

Gestational Age

Total/Direct Bili Level

Date of Collection

Time of Collection

Time

HoursMinutes

Anything else you would like us to know

Insurance Carrier and Number (if available)

HOME PHOTOTHERAPY ORDER

The Perfect Push, PLLC will provide home phototherapy for continuous use.

The Perfect Push, PLLC (TPP) will provide home phototherapy for continuous use using the Skylife Neonatal Phototherapy System or other device depending on equipment availability. TPP RNs will provide parents with instruction on the use of the equipment.

*A daily nursing assessment with weight, vital signs and a STAT Neonatal Bilirubin T/D via heel stick will be performed daily while the baby is under our care and part of this service. Length of home care services will be evaluated daily by MD based on results.

OUTPATIENT BILIRUBIN ORDER

The Perfect Push, PLLC (TPP) will provide skilled nursing assessment with weight, vital signs and a STAT Neonatal Bilirubin level T/D via heel stick. Length of home care services will be evaluated daily based on results by the MD.

Lab Draw Only Orders

Please indicate the date and requested collection time below.

Bilirubin Collection Date

Requested Collection Time

Time

HoursMinutes

LACTATION CONSULT ORDER

The Perfect Push, PLLC will provide feeding and lactation services to both infant and mother.

DIAGNOSIS

Neonatal Jaundice, unspecified (P59.9)

ABO Isoimmunization of the Newborn (P55.1)

Encounter for care and examination of lactating mother (Z39.1)

Short answer

Signature

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Printed Name

Practice Name

Phone Number

Fax Number

NPI Number

Additional Contact Information for Results

Sent automatically to referrals@theperfectpush.com

In-Home Phototherapy Order Form

Outpatient Phototherapy/Bilirubin

Order Form

HOME PHOTOTHERAPY ORDER

OUTPATIENT BILIRUBIN ORDER

LACTATION CONSULT ORDER

DIAGNOSIS

The Perfect Push Difference

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