Generic Referral Form - Alberta Health ?· Generic Referral Date (yyyy-Mon-dd) Refer to Fax Referring…

Download Generic Referral Form - Alberta Health ?· Generic Referral Date (yyyy-Mon-dd) Refer to Fax Referring…

Post on 25-Jul-2018




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<ul><li><p>Generic Referral</p><p>Date (yyyy-Mon-dd) Refer to Fax</p><p>Referring provider/source Phone</p><p>Address Fax</p><p>Family Physician</p><p>Guardian/Appointed Agent (if applicable)</p><p>Patient Guardian Name Phone Relationship</p><p>Please type directly into the form. Where indicated, required referral information may be attached. Please ensure referral meets specifi c referral requirements where these are available.</p><p>19619(Rev2017-11)</p><p>Referral InformationReason for referral </p><p>Type of referral New referral Re-referral 2nd opinion Urgent referral Service/consultant is aware of urgent referralReason for urgency ____________________________________________________________________________</p><p>Specialist seen previously No Yes If Yes Date seen If Yes Diagnosis Diagnosis Date (yyyy-Mon-dd)</p><p>Prior hospital admission (past 2 years) No Yes (If yes, when and where?) Currently hospitalized, where? Past Medical History Attached</p><p>Current Medications/Allergies Attached</p><p>Requested Action Confi rm and/or advise diagnosis Assume future management of patient within area of expertise Confi rm and/or advise management, including medication Telephone consultation Assume management for this problem and return patient after care Patient educationProcessing Requirements (Check if included) Blood work Diagnostic imaging Consultant letters Discharge summaries Microbiology PathologyFactors that may affect consultation/careSpecifi c patient request Physician Location Language Interpreter required Physical limitations Social/Psychological Economic Other For offi ce use only</p><p>Name Signature Designation Date (yyyy-Mon-dd)</p><p>Refer to: Address: Family Physician: Reason for referral: Reason for urgency: If Yes Date seen: Past Medical History: Current MedicationsAllergies: Blood work: Diagnostic imaging: Consultant letters: Discharge summaries: Microbiology: Pathology: Language: Interpreter required: Physical limitations: SocialPsychological: Date: Phone: Fax: Fax_2: Referring provider/source: If Yes Diagnosis: If Yes Diagnosis Date: Past medical history_Attached: Current Medication/Allergies attached: Specific patient request: Physician Name_patient request: Location_patient request: Locatione_patient request: Economic: Others: For ofce use only: Office Only_Designation: Office Only_Name: Office Only_Date: Prior hospital admission: Prior hospital admission_where: Currently hospitalized: Currently hospitalized where: Specialist seen previously: new Referral: Re- Referral: 2nd Opinion: Urgent referal: Service/consult: Confirm diagnosis: Confirm management: Assume management: Assume future management: Telephone consultation: Patient Education: Guardian name: Guardian phone: Guardian/appointed agent: Guardian relationship: </p></li></ul>


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