Get Referral Form - Concussion Care - Concussion-care

Filling out the REFERRAL FORM for concussion care is essential for ensuring effective treatment and support. This guide will walk you through each section of the form, providing clear instructions to help you complete it accurately and efficiently.

Follow the steps to complete the referral form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. In the 'CLIENT DETAILS' section, fill in the client's name, date of birth, home address, postal code, and phone numbers (home and cell). Also, include the email address, date of injury, and a brief description of the diagnosis or injuries sustained.
3. Moving to the 'REFERRAL INFORMATION' section, indicate the date of referral, the referral agency's phone number and fax number, and provide the contact person's name and email. Additionally, specify the funding source, such as self or insurer, along with the claim number if applicable.
4. In the 'MEDICAL INFORMATION' section, enter the name and address of the family physician along with their phone and fax numbers. Note the number of years the client has been with that doctor and list any other medical specialists involved in the care.
5. For the 'INJURY DESCRIPTION,' briefly explain how the injury occurred. Indicate whether there was any loss of consciousness and if any formal tests (like CT or MRI) were performed, including the length of time before testing. If tests were done, summarize the results.
6. In the 'SYMPTOMS' section, check any symptoms that have increased since the injury, such as headaches, dizziness, or fatigue. Make sure to review all symptoms listed.
7. Address the 'RISK FACTORS' section by noting any past pre-existing health issues, such as previous concussions or other relevant conditions, and provide explanations as needed.
8. Articulate the 'EXPECTED GOALS AND OUTCOMES OF PROGRAM' clearly, specifying what is hoped to be achieved through the concussion care program.
9. In the 'ADDITIONAL DATA / COMMENTS' section, include any further comments or information that may be relevant to the referral.
10. Once all sections are complete, review the information for accuracy. You can then save changes, download, print, or share the form as required.

Complete your referral form online today to ensure timely access to concussion care!