Follow the steps to ensure a smooth completion of the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the patient name in the designated field. Ensure that the name matches legal identification documents.
3. Fill in the patient address. Include complete details such as street, city, province, and postal code for accurate identification.
4. Input the date of birth in the required format (MM/DD/YYYY). This information helps verify the patient’s age.
5. Provide the health card number if available. This serves as an identification number for medical services.
6. Enter the home or cell phone number for patient contact purposes. Please ensure the number is current and reachable.
7. If applicable, choose the medical condition or symptoms leading to this referral by checking the respective boxes or noting them down. Review the list thoroughly.
8. In the 'Reason for Referral' section, elaborate on the conditions that prompted the referral. This field is required.
9. Enter the name of the referring medical doctor. This should be the physician initiating the referral.
10. Fill in the referring MD billing number. This is essential for billing and processing purposes.
11. Provide the signature of the referring medical doctor to validate the referral. This could be done electronically if needed.
12. Date the referral accurately to indicate when the referral was initiated.
13. Review all entries for accuracy and completeness. Make any necessary corrections.
14. Save changes, download the completed form, print it for your records, or share it electronically as required.

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