Get Canada Regional Colonoscopy Network Referral Form 2012-2025

Filling out the Canada Regional Colonoscopy Network Referral Form online is an essential step for facilitating timely healthcare services. This guide provides clear, step-by-step instructions to help you complete the form efficiently and accurately.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's personal information. This includes the name, address, apartment number (if applicable), postal code, date of birth (day, month, year), home phone number, business or other phone number, age, sex, and city or town of residence. Ensure accuracy in all details.
3. Indicate whether permission is granted to contact the patient at the provided number by selecting 'Yes' or 'No' and fill in the health card number and associated code.
4. Next, complete the referral information section. The referring physician must provide their name, telephone number, and fax number, as well as sign the form to confirm the referral.
5. Provide the reason for referral based on the RCN criteria, making sure to attach any required documents, such as the copy of the FOBT result if it is a positive test.
6. Indicate if the patient has undergone a previous colonoscopy and provide any operative or pathology reports if applicable. Be aware of the conditions that require a referral to a gastroenterologist or general surgeon.
7. Fill out the patient’s medical history by listing current medications and any allergies. Include special considerations if necessary, such as the need for an interpreter or assistance due to hearing impairment.
8. Check any relevant medical conditions from the provided list, ensuring all applicable ones are marked accurately.
9. In the RCN use-only section, leave spaces for the physician performing the procedure and relevant dates to be filled by the RCN staff during processing.
10. Once all sections are completed and verified for accuracy, save changes, then download or print the form accordingly for faxing to the designated number.

Complete the Canada Regional Colonoscopy Network Referral Form online today to ensure prompt processing of your referral.