Get Guelph General Hospital Sleep Lab Referral Form

This guide provides clear, step-by-step instructions for filling out the Guelph General Hospital Sleep Lab Referral Form online. By following these steps, users can ensure accurate and complete submissions for sleep study referrals.

Follow the steps to complete your referral form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Select a sleep physician to whom the requisition will be faxed. Choose from Dr. Vasanti Shende, Dr. Jackie Nemni, or Dr. Jamie Le by marking the appropriate box.
3. Enter the patient's name in the provided field, specifying gender by checking the relevant box (male or female).
4. Fill in the patient's address, home phone number, alternate phone number, and email address in the designated fields.
5. Provide the patient's date of birth (in the format dd, mm, yy) and health card number.
6. Enter the primary care provider’s name in the specified field.
7. Indicate the service requested by checking either 'Sleep Study and Consultation' or 'Sleep Study Only.' Include the date of request.
8. Complete the referring physician's information, including their name and billing number, address, phone number, and fax number.
9. Obtain the physician's signature in the designated area.
10. Provide the reason for the referral in the available space.
11. Check all applicable co-morbidities from the given options.
12. Indicate if the patient has a safety critical occupation or if they are at high risk of a car crash by checking the relevant box.
13. Provide details about any previous sleep studies and any current or prior usage of CPAP, BIPAP, or oxygen, as well as addressing special needs if necessary.
14. The appointment information section will be completed by the sleep physician’s office.
15. After filling in all details, save changes, download the form, print it for personal records, or share it as needed.

Complete your Guelph General Hospital Sleep Lab Referral Form online today for a smooth referral process.