Get Rivlin Pain Clinic Referral Form

Filling out the Rivlin Pain Clinic Referral Form online is a straightforward process designed to ensure that all necessary information is accurately collected. This guide will provide you with detailed steps to help you navigate each section of the form efficiently.

Follow the steps to complete your referral form successfully.

1. Press the ‘Get Form’ button to obtain the Rivlin Pain Clinic Referral Form and open it for completion.
2. In the 'Patient Demographics' section, enter the patient's name, date of birth, address, health card number, and telephone number. Ensure all details are provided clearly to avoid any confusion.
3. Under 'Referring Source information,' input the name, address, phone number, fax number, and back line of the referring physician. Remember, the MOH Physician number is mandatory; referrals without it will be returned.
4. If the family physician differs from the referring source, fill in their details in the section provided, ensuring that all required fields are completed.
5. Mark all applicable diagnoses and syndromes from the list provided, making sure to include 'Other' if necessary with a brief description.
6. Indicate any known history of alcohol or drug abuse by selecting 'Yes' or 'No' and provide answers regarding previous assessments or treatments at chronic pain facilities.
7. Fill out the duration of pain and past treatment history in the specified fields, offering as much detail as possible for better patient management.
8. State the desired outcome of the pain specialist consultation and indicate if an epidural is requested by checking the corresponding box.
9. In the 'Additional clinical information' section, provide any other pertinent details that may assist in the referral process.
10. Attach all mandatory documents listed, including a complete medication list and pertinent scans, to ensure the referral is processed without delay.
11. Finally, the referring physician must sign the form. Once completed, follow the instructions to fax the form to the provided number.

Begin filling out the Rivlin Pain Clinic Referral Form online today to ensure a seamless referral process.