DOCTOR INFO

HOME
ABOUT US
OUR SERVICES
PATIENT INFO
DOCTOR INFO
CONTACT US

HOME
ABOUT US
OUR SERVICES
PATIENT INFO
DOCTOR INFO
CONTACT US

DOCTOR REFERRAL FORM

The Rudd Clinic and Provis Endoscopy Clinics would like to thank you for your support in the past and look forward to serving
you and your patients in the future.

Referral Form 2016
File Size:	161 kb
File Type:	pdf

Download File

Clinic Location *

Toronto Mississauga Oakville Ottawa

Date DD/MM/YYY *

Referred to Specific Physician *

Gender *

Male Female

Patient Name *

First

Last

Referring Doctor *

First

Last

Patient Address *

Doctor Address *

Health Card No. *

Date of Birth DD/MM/YYYY *

Physician Referring No. *

Patient Daytime Phone *

Patient Evening Phone *

Physician Phone No. *

Physician Fax No. *

Reason for Consult *

GI Endoscopy evaluation and pre-operative Internal Medicine consultation

*Pre-operative Out of Hospital (OHP) requirements for endoscopy

As we are an out of hospital premise it is important to engage in a full pre-endoscopy consultation to determine all risk factors and suitability for undertaking the endoscopic procedure and anesthesia in an out of hospital facility.

Patient Weight (Lbs) *

Anorectal Problems *

Abcess/Hematoma Fissure Fistula Hemorrhoids Rectal bleeding

Other *

Colonoscopy & Pre-Op Consult *

Screening Rectal bleeding/FOBT positive Family history Abdominal pain

Other *

Gastroscopy & Pre-Op Consult *

Option 1 Option 2 Option 3

Other *

PATIENT MEDICAL HISTORY

Please check *

HX of adverse reaction to sedation/anaesthesia On anti-coagulants ASA or Plavix AI/Unstable angina last 6 months Diabetes Mellitus

Type *

1 2

Please check *

Emphysema/Severe COPD Ambulatory Prosthetic heart valve Abnormal renal function

Other *

Patient Medications *

PLEASE NOTE:
We will make 3 attempts to contact the patient. Your patient can call for an appointment 3 business days after referral is sent.

Additional Referral Forms *

Yes No

Submit

Create your own unique website with customizable templates.