Get Physician Referral Form Factt-dd - The Royal

Filling out the Physician Referral Form FACTT-DD - The Royal is essential for individuals seeking services from the Dual Diagnosis Services of the Community Mental Health Program. This guide provides clear, step-by-step instructions to assist users in completing the form efficiently and accurately.

Follow the steps to complete the form seamlessly.

1. Click ‘Get Form’ button to obtain the form and open it in your editing tool.
2. Begin by filling in the client name and date of birth (DOB) in the designated fields. Ensure that the information is accurate as it identifies the individual receiving the referral.
3. In the client information section, select the appropriate gender, language preference, marital status, and indicate if the individual has Aboriginal origin. If a translator is required, mark 'Yes' or 'No' accordingly.
4. Fill in the client's address, preferred phone number, postal code, alternate phone number, and OHIP number as requested. This information is vital for contact purposes.
5. Provide the primary caregiver's contact information, including their name, relationship to the client, address, postal code, and preferred phone number.
6. Next, complete the next of kin contact information if different from the primary caregiver. Include their name, relationship, address, postal code, and preferred phone number.
7. Indicate if there is a substitute decision-maker. If yes, provide their details including name, relationship, address, postal code, and preferred phone number.
8. Provide the family physician's name, phone number, address, fax number, postal code, and email if applicable.
9. In the referral information section, list the name and contact information of the referring physician if different from the family physician. Ensure to include relevant fax number and email.
10. For the reason for referral, select all options that apply and provide a description of clinical questions as specifically as possible.
11. Complete the diagnosis section by documenting any intellectual disability, psychiatric diagnosis, and medical diagnosis as necessary. Attach any required assessments or results.
12. Include the date of the last complete physical examination and relevant medical documentation.
13. List any current medications and ensure to fax this list along with the referral.
14. Address any barriers to obtaining information, and clarify if the client has seen any specialists or is supported by community agencies.
15. Finally, add any additional information regarding current health issues before signing and dating the form as completed.
16. Save your changes, and download, print, or share the form as needed.

Complete the Physician Referral Form FACTT-DD - The Royal online today for efficient processing of your referral.