Get Canada St. Josephs Health Care London Cardiovascular Investigation Unit Referral Form 2023-2025

Filling out the Canada St. Josephs Health Care London Cardiovascular Investigation Unit Referral Form online is a straightforward process that ensures accurate and efficient referrals for cardiovascular assessments. This guide provides detailed instructions to help you complete each section of the form effectively.

Follow the steps to successfully complete the referral form.

1. Click the ‘Get Form’ button to obtain the referral form and open it in your online document editor.
2. In the 'Patient Information' section, fill in the patient’s surname and given name as accurately as possible. Enter the patient's date of birth and select their sex. Lastly, input the health card number.
3. Provide the full address of the patient, including city and postal code. Enter the home phone number and an alternate contact number if available.
4. Fill out the date of referral in the YYYY/M/D format and include the PIN# or J# if applicable.
5. In the 'Referring Physician Information' section, print the name of the referring physician and their physician number. Complete the address, city, postal code, phone, fax, and email of the physician.
6. Ensure the signature field is signed. If there is a family doctor who is different from the referring physician, list their name in the designated area.
7. In the 'Reason for Exam/Clinical History' section, provide a detailed description of the reason for the referral.
8. Indicate whether the patient has an intracardiac device by marking the appropriate box, such as pacemaker or ICD/CRT.
9. Select the type of test required by checking the appropriate box, for example, echocardiogram or exercise stress test.
10. If the patient requires assistance for transfer, mark the appropriate option from the choices provided.
11. Complete the appointment date and time fields, ensuring to inform the patient to arrive 20 minutes early for their appointment.
12. Once all fields are filled, review the information for accuracy. Users can save changes, download, print, or share the form as necessary.

Start completing your referral form online today to ensure a smooth process for cardiovascular assessments.