Get Physician Referral Form For Lymphedema Assessment - Winnipeg ...

Completing the Physician Referral Form for Lymphedema Assessment in Winnipeg is a crucial step in connecting patients with the necessary care. This guide will lead you through each section of the form to ensure you provide accurate and complete information, facilitating an efficient referral process.

Follow the steps to complete the form online.

1. Select the ‘Get Form’ button to access the Physician Referral Form for Lymphedema Assessment. This will open the document in your preferred editor, allowing you to fill it out conveniently online.
2. Begin with the client health record number section. Enter the client's unique identifier if available, followed by their surname, given name, and date of birth in the specified format.
3. In the gender field, indicate the appropriate category, followed by the MFRN (Medical Facility Registration Number) and PHIN (Personal Health Identification Number) if applicable.
4. If applicable, complete the address section for home visits, ensuring you provide accurate details to facilitate appropriate care.
5. In the referring physician section, provide the name, address, and contact information of the healthcare professional making the referral. This is essential for follow-up communication.
6. Gather and input patient information accurately, including their home, work, and cell phone numbers, and the provider number if available.
7. The authorized clinician signature should be signed along with the date, weight, and height of the patient. Ensure these fields are filled out clearly to avoid any discrepancies.
8. Specify the reason for referral by selecting appropriate options regarding the patient’s lymphedema needs and any comorbid conditions that might be relevant.
9. Indicate the history of any breast surgeries, the type of procedure performed, and the year of surgery for both breasts. Ensure that the information accurately reflects the patient’s medical history.
10. Conclude by filling out areas related to chemotherapy and radiation treatments, including years administered and areas treated. This provides critical context for the assessment.
11. Once all fields are filled out completely and accurately, save your changes. You may also download, print, or share the form as needed for submission.

Ensure timely access to care by completing the Physician Referral Form for Lymphedema Assessment online today.