Telemedicine Consult Adult Referral Form

* = Required

Referral Information

* Date of Referral

Physician Information

City

Address

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          

* Aboriginal Status  

* Preferred Language    

* Card Expiry Date

Card Version Code (if applicable)

Psychiatric Information

Medication Information

Medication Name

Date Started

Dosage

Effectiveness

+ 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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