Get Foot And Ankle Screening And Triage Clinic - Queensway Carleton - Qch On

Filling out the Foot And Ankle Screening And Triage Clinic referral form can be a straightforward process when approached methodically. This guide will help you navigate each step to ensure that all necessary information is accurately provided for your referral.

Follow the steps to complete your referral form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Enter the patient's name in the designated field. Ensure that the name is spelled correctly and matches official identification documents.
3. Input the patient's birth date using the format (yy/mm/dd). This information is crucial for identification purposes.
4. Fill in the patient's address, ensuring that all relevant details are included for effective communication.
5. Provide the postal code, necessary for postal services to reach the patient.
6. Enter the home phone number, and if applicable, provide an alternate phone number or specify if it is a Workers' Safety and Insurance Board (WSIB) case.
7. Input the OHIP number, which is essential for processing the referral through healthcare services.
8. If referencing a hospital, include the name of the referring hospital alongside the family physician's information, if different from below.
9. Specify the reason for referral by selecting one or more options related to forefoot conditions, indicating whether the issue pertains to the right or left foot.
10. Complete the referring physician's details, including their name, billing number, address, phone number, and fax number for correspondence.
11. Add the signature and date where indicated to validate the referral. This step is important for approval and processing.
12. If available, gather and send or fax any required additional information, including patient reports and imaging results.
13. Once all fields are thoroughly reviewed and completed, save the changes, and choose to download, print, or share the form as needed.

Complete your referral form online today to ensure timely processing and care.