Get Carlo Fidani Regional Cancer Centre Patient Referral Form

Filling out the Carlo Fidani Regional Cancer Centre Patient Referral Form online is an essential step in ensuring that patients receive timely care. This guide will provide clear instructions to help you navigate each section of the form effectively.

Follow the steps to complete the patient referral form with ease.

1. Press the ‘Get Form’ button to obtain the form and open it for completion.
2. Begin with the patient information section. Enter the patient's last name, first name, health card number, version, and date of birth in the specified format (dd/mm/yyyy). Select the appropriate gender and indicate if interpreter services are required by checking 'Yes' or 'No', specifying details if applicable.
3. Fill out the patient’s address details including street address, city, province, and postal code. Provide various contact numbers: home, cell, and work, along with an alternate contact name, their relationship to the patient, and their phone number.
4. Complete the referring physician section. Include the referring physician’s name, billing number, contact phone number, fax number, and obtain their signature.
5. Provide information about the family physician by entering their name, phone number, and fax number.
6. In the 'Reason for Referral' section, give detailed information about the patient's condition and the reason for referral. Ensure to note the requested service and specific physician preferences if applicable, selecting from the list provided.
7. Indicate whether the patient is informed of their diagnosis by checking 'Yes' or 'No' and include any relevant documentation such as blood work, pathology results, imaging, and consultation notes if available.
8. For office use, there are boxes to check whether the case is benign, malignant, or unknown. Leave this section blank as it is for administrative use.
9. Lastly, save your changes, and you can choose to download, print, or share the completed form as needed.

Complete the Carlo Fidani Regional Cancer Centre Patient Referral Form online today to ensure comprehensive care for patients.