Follow the steps to efficiently complete the referral form.

1. Click ‘Get Form’ button to access the referral form and open it in the online editor.
2. Enter the patient's name in the designated field, ensuring it is spelled correctly. This is essential for accurate identification.
3. Fill in the date of birth (DOB) and check the gender box appropriate for the patient. Use ‘M’ for male, ‘F’ for female.
4. Provide the patient's Personal Health Number (PHN) and Medical Record Number (MRN) in the specified fields.
5. Input the patient's address and telephone number, ensuring all information is current for future contact.
6. In the 'Referring physician/NP' section, print the name of the referring physician or Nurse Practitioner clearly.
7. Select the referral source by checking the appropriate box, such as 'Primary care' or 'Cardiologist.'
8. Indicate the patient's AF diagnosis status by checking either 'Newly diagnosed' or 'Previously diagnosed.'
9. Specify the purpose of the referral by checking the relevant options, such as cardiologist assessment for opinion or consultation.
10. Detail any symptoms experienced when in AF in the provided section, which will assist in understanding the patient's condition.
11. Check all applicable indications for referral, such as assistance with stroke prevention or medication trials.
12. If a cardiologist assessment is requested, indicate preferences for the cardiologist by marking the box next to their name.
13. Provide a comprehensive AF treatment history, documenting any medication trials, cardioversions, or ablations the patient has undergone.
14. Specify where to send the cardiologist consult notes in the respective field.
15. Ensure all required documents, including the 12 Lead ECG or Holter documentation, are noted in the 'We require the following to process the referral' section.
16. Complete any additional cardiac history or comments that are relevant to the referral.
17. Finalize the form with the physician or NP's signature, along with their phone number.
18. Once all fields are filled out, save changes, and you may choose to download, print, or share the completed form as needed.

Complete your Afib Clinic Victoria Bc referral form online today for timely medical assistance.