Transcription of Last Name First Name Generic Referral
1 Generic Referral Date (dd/Mon/yyyy)Refer toPatient AddressPhoneReferring Provider/SourcePhoneReferring Provider AddressFaxFamily PhysicianLegal Guardian NamePhoneRelationshipEnsure Referral meets specifi c Referral requirements where these are available. For more information on criteria and where to send the Referral visit: Referral form could also be completed electronically within the Telus Health and Accuro EMRs using the QuRE Consultation- Referral Request and Response (Rev2020-01)Who has been informed of the reason for this Referral ? Patient Guardian Patient and GuardianAdditional Patient Information Patient has guardian Patient has alternative contact Patient unable to communicate well in English Patient has vision requirements Patient has hearing requirements WCB claimSpecial Considerations Interpreter required Physical limitations Social / Psychological Economic Details.
2 _____Referral InformationReason for Referral Type of Request Advice ConsultPriority of Referral Routine Urgent EmergentPatient s Current Status Stable WorseningPatient ExpectationFindings and/or investigationsCurrent and Past ManagementMedical HistoryActive MedicationsAllergiesSurgical HistoryFamily HistoryInformation given to patientCompleted ByNameSignatureDesignationDate (dd/Mon/yyyy)Last Name (Legal) First Name (Legal)Preferred Name Last FirstDOB(dd-Mon-yyyy)PHNULI Same as PHNMRNA dministrative Gender Male Female Non-binary/Prefer not to disclose (X)
