C-endo(adivisionofC-health)6720–104StreetNW

Edmonton,ABT6H2L4Phone:(780)306-5555

Fax:(780)431-2554www.c-health.ca

PleaseNote:Wewillfaxtheappointmentdateandtimetoyourofficeandnotifythepatientbyphoneorletter.Thepatientmayrequirelabstobecompletedpriortothisappointmentandalabrequisitionwillalsobesenttothepatient.Werequire48-hournoticeforcancellationorreschedulingofappointment.

RelevantHistory:ReferringPhysicianSignature:

C-ENDO-ACENTREOFEXCELLENCECOMMITTEDTOCOMPREHENSIVEDIABETESANDENDOCRINOLOGYCARE

DateofReferral:

PATIENTINFORMATION(orattachpatientlabel)

PatientName:

ULI#:

Phone:

Address:

City,Prov.: PostalCode:

DateofBirth: Gender: Male Female DAY/MONTH/YEAR

Fortriageofreferralspleasecheckoneofthefollowing:

DIABETESMANAGEMENT

ENDOCRINOLOGISTGENERALINTERNISTNOPREFERENCE,SHORTESTWAITTIME

GENERALENDOCRINOLOGY

THYROIDDISORDERFEMALEREPRODUCTIVEMALEREPRODUCTIVEOSTEOPOROSISCALCIUM/PARATHYROIDBARIATRICMATTERSPITUITARY/ADRENALOTHER

URGENT FIRSTAVAILABLE ROUTINE

Note:Pleaseensurepatientdemographicsarecurrent.

ReferringPhysician:

Ph: Fax:

PracticeID:

AdditionalReportto:

Fax:

UpdatedApril2016