Get Referral Form - Trillium Health Partners

Completing the Referral Form for Trillium Health Partners is a straightforward process designed to assist healthcare professionals in referring patients to the West GTA Regional Stroke Prevention Clinic. This guide provides step-by-step instructions to ensure that all applicable fields are accurately filled out for efficient processing.

Follow the steps to complete your referral form.

1. Click ‘Get Form’ button to access the referral form and open it for editing.
2. Begin with the 'Referring Physician' section. Clearly print your name, address, hospital affiliation, and contact phone numbers in the designated fields.
3. Next, fill in the 'Patient Name' field with the full name of the patient you are referring.
4. Complete the 'Date of Birth' and 'OHIP Number' fields with the patient's details. Ensure these are accurate to avoid processing delays.
5. Specify the 'Referring From' section by selecting the appropriate option: ER Department, Family Practice, or Other. Check the box that applies.
6. If applicable, indicate if you would like the patient to be booked for Carotid Dopplers by checking the designated box.
7. In the ABCD2 scoring section, fill in the scores based on the patient's clinical presentation and medical history.
8. Document the 'Date of Event' in the format indicated (day/month/year) and provide the patient's age and blood pressure in the required fields.
9. Check all appropriate clinical features that apply to the patient, including any motor or sensory disturbances, and note the duration of symptoms.
10. List any risk factors associated with the patient’s condition by checking all relevant boxes.
11. Review all information for accuracy and completeness. Ensure that you have checked the box to agree to fax the referral form along with all current investigations or blood work.
12. Once all details are filled in, you can save changes, download, print, or share the completed form as needed.

Complete your referral form online today for efficient processing and care.