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PEDIATRIC (DOC)

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					                             PEDIATRIC AMBULATORY CLINICS – MUMC
                                        REFERRAL FORM
                              Adolescent Medicine, Cystic Fibrosis, Diabetes, Eating Disorders,
                                       Endocrine, General Pediatrics, General Surgery,
                                      Immunology/Rheumatology, Neo-Natal Follow Up,
                             Obstetrical Brachial Plexus Injury, Orthopedics, Plastics, RSV clinic,
                                                           Urology.
                                              2Q Clinic Fax (905) 521-5056

REFERRAL REQUEST TO: _____________________                         ______________________
                              (Specialty- must be included)                   (Physician)

         ***ACCURATE AND LEGIBLE COMPLETION OF THE REFERRAL FORM IS ESSENTIAL***

 REFERRING PHYSICIAN INFORMATION:                       PATIENT INFORMATION:

 NAME:
                                                        NAME:                                M□       F   □
 ADDRESS:
                                                        ADDRESS:

 POSTAL CODE:
                                                        POSTAL CODE:
 TEL#:
 FAX#:                                                  TEL#:
                                                        PARENT/GUARDIAN’S NAME:
 EMAIL (optional):                                      __________________________________________

 PHYSICIAN BILLING #: ________________                  HEALTH CARD #:_________________________
                                                                    (Please include Version Code)

FAMILY HAS BEEN MADE AWARE OF THIS REFERRAL:             □YES      □NO
                     PLEASE CALL THE PHYSICIAN DIRECTLY IF THIS REQUEST IS URGENT

 REASON FOR REFERRAL:


 BRIEF HISTORY: (PLEASE ATTACH RESULTS OF INVESTIGATIONS RELEVANT TO THIS REFERRAL)




 MEDICATIONS:




                                                              Physician Signature: __________________


                                      CLINIC USE ONLY
 Referral Received by:__________________     date:________________dd/mm/yy

 Clinic and Clinician Assigned to for triage: ___________________________________________

				
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posted:11/3/2011
language:English
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