Dear Doctor,

 

Your patient, _______________________, has applied to participate in WAVE, the NJ shore getaway for children 

 who have tracheostomies, who are ventilator-dependent, or have specialized medical needs.  Please refer to the informational brochure for details. 

 

Please review your patient's application information

 (enclosed) for accuracy and completeness.

 

 

Patient's Diagnosis (medical issues):

 

   

   

   

   _______________________________________________________________

   

 

 Your patient should be medically stable to participate in WAVE. 

Of note, your patient may not be attending with his/her usual

home caretakers, in order to foster independence and maturation.  Participants will be cared for at the getaway by experienced professionals.

 

Do you believe that _________________________________

is medically stable to participate in

WAVE?                                                              

 

ÿ  YES  ÿ NO      

 

 

Comment:

  

   

To the best of my knowledge, the above information

 is correct

 

Date   ______________                   

 

Name __________________________________      

Title __________________

 

 

Address ________________________________________

 

              ________________________________________   

             

              ________________________________________   

 

 

 

For additional questions or comments, please call the WAVE coordinating Physician:

Caitlin Papastamelos, MD

Pediatric Pulmonology

1-609-926-0962