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VOICE CLINIC REFERRAL FORM

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VOICE CLINIC REFERRAL FORM Powered By Docstoc
					                                                                                              Patient Name: __________________________
                                                                                              Date of Birth: ____M        /   D /       Y______
                                                                                              Address: ______________________________
                                                                                              ______________________________________
VOICE CLINIC REFERRAL FORM
                                                                                              ______________________________________
                     M         /      D         /      Y                                      Phone: (_______)_______________________
Date: __________________________
       REFERRAL IS FOR:                                          Assessment by Dr. Jennifer Anderson                     Voice therapy only

                          PRIORITY:                               Urgent            Within one month                     As available

Structural:                                                                         Non-Structural:
   Nodules                                                                            Muscle Tension Dysphonia
   Polyp                                                                              Vocal Abuse/Misuse
   Reinke’s edema/polypoid degeneration                                               Vocal Fatigue
   Laryngitis ( acute /                        chronic)                               Ventricular Phonation
   Sulcus vocalis                                                                     Puberphonia/mutational falsetto
   Presbylarynges or Bowing                                                           Transgender Voice
   Scarring                                                                           Conversion/Whisper Aphonia
   Other: __________________________________                                          Other: _____________________________________
Neurogenic:
   Paralysis: ( Right /                        Left)            Muscle involved: ( PCA /    Cricothyroid /    Vocalis)
   Suspected Spasmodic Dysphonia
   Essential Tremor
   Other: _________________________________________________________________________________
Idiopathic Disorders:                                                                Systemic Disease:
     Chronic Cough                                                                         Gastroesophageal Reflux
     Paradoxical Vocal Cord Dysfunction                                                    Respiratory Disease: _______________________
     Congenital Anomaly                                                                    Other: __________________________________
      (Please specify):                                                    ______                __________________________________


Additional Information/Requests:
                                                                                                ________________________________
                                                                                                ________________________________
                                                                                                ________________________________
                                                                                                ________________________________
                                                                                                ________________________________
                                                                                                ________________________________


                                                                                                             MAIL/FAX TO:
                                                                                       VOICE CLINIC
Physician Name:                           _______________________
                                                                                       Mount Sinai Hospital
                                                                                       Ste. 201, 600 University Avenue, Toronto, ON M5G 1X5
Physician Signature: _______________________
                                                                                       Ph: (416) 586-4800 ext. 7177 Fax: (416) 586-4807
 t/slpinfo/voiceclinic/fax templates/vc referral form July 09

				
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