Physician Referral Form Toll Free Phone: 18882827763 Toll Free Fax: 18443209652 www.cmclinic.ca Patient Information: Name: DOB: Health Card # Address: City: Postal Code: Phone: (W) (H) (C) Email (required):.
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How to fill out the 18882827763 online
Filling out the 18882827763 form online is a straightforward process that ensures accurate and efficient submission of important health information. This guide will lead you through each section of the form, making it clear and accessible for all users.
Follow the steps to complete the form efficiently.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by entering the patient information in the designated fields. Include the patient's name, date of birth, health card number, address, city, postal code, and multiple phone numbers (work, home, and cell). Ensure that the email address is filled out as it is required.
- In the referral to service section, select the appropriate checkbox for the patient's needs, either assessing suitability for medical cannabis or any other specified request. This section allows you to indicate critical details regarding the patient's health status.
- Address the questions related to the patient's medical history. Indicate whether the patient is taking anti-coagulants, is pregnant or trying to become pregnant, has a significant communicable disease, or has untreated substance abuse/addiction.
- Complete the systemic/other conditions section by checking any applicable conditions such as chronic pain, cancer, or neurodegenerative diseases, providing specifics where indicated.
- For mental health conditions, check the relevant boxes, including anxiety/depression, PTSD, and sleep disorders. This helps clarify the patient's overall health picture.
- Indentify any current medications and medications previously tried for the current condition in the provided spaces.
- Proceed to the physician information section, providing the referring physician's name, phone number, signature, and billing number. Indicate if you are a member of a FHO/FHN/FHT if applicable.
- Finally, select the appropriate clinic location and check the telemedicine option if relevant. Make sure to attach any pertinent medical history, scans, and consults associated with the patient's treatment.
- Once you have filled out all sections accurately, review the information for any errors or omissions. Save your changes, and you can then download, print, or share the form as necessary.
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