Telemedicine Consult Adult Referral Form

* = Required

Referral Information

* Date of Referral

Physician Information



Postal Code

* Phone xxx-xxx-xxxx

Fax xxx-xxx-xxxx

Patient Information

* Address

* City/Town

Postal Code

Phone (Home) xxx-xxx-xxxx

Phone (Cell) xxx-xxx-xxxx

* Date of Birth

* Gender          

* Indentifies as Indigenous  

* Preferred Language    

* Card Expiry Date

Card Version Code (if applicable)

Psychiatric Information

Medication Information

Medication Name

Date Started



+ Add Another Medication

Recent Hospitalizations


 + Add Hospitalization

Mental Status

Check all that apply:

Risk Assessment

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  • Is the individual expressing interest in addressing his/her current substance abuse problem?

  • Is the individual impacted negatively by their own or someone else's gambling?

Other Agencies Involved

Investigation Notes

E.g. CBC, TSH, electrolytes, glucose, lipids, prolactin, LFT's, Cr, B12
including drug levels if available and CT Scan, EEG, EKG

E.g. Consultation notes, assessments, and discharge summaries

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