Get Canada Nygh Colorectal Cancer Diagnostic Assessment Program Referral Form 2024-2025

This guide provides clear and supportive instructions for completing the Canada NYGH Colorectal Cancer Diagnostic Assessment Program Referral Form online. Following these steps will help ensure that the referral process is smooth and efficient.

Follow the steps to complete the referral form successfully.

1. Press the ‘Get Form’ button to retrieve the referral form and open it in your preferred document editor.
2. Fill in the 'Date of Referral' section to indicate when the referral is being made. This is important for tracking the referral timeline.
3. In the 'Patient Information' section, provide the patient's last name, first name, date of birth (DOB), OHIP number, gender, address, city, postal code, and preferred phone number. This information is critical for patient identification and contact.
4. Complete the 'Referring Physician' section by entering your name, billing number, phone number, and fax number. Ensure this information is accurate to facilitate communication.
5. Indicate the 'Reason for Referral'. Choose the appropriate box that applies: New colorectal cancer, second opinion, or symptoms highly suspicious for colorectal cancer. If applicable, specify details such as early onset or elder onset.
6. Provide a brief medical history in the 'History' and 'Past Medical History' fields. This helps the medical team understand the patient's background.
7. If any endoscopies have been performed, check the corresponding boxes and ensure to attach any available reports or pathology results.
8. Specify the tumor location if applicable. Options include right, transverse, left or sigmoid, or rectum (less than 15 cm from anus).
9. In the 'Imaging' section, indicate which imaging procedures have been performed (CT or MRI) and specify the regions (chest, abdomen/pelvis, rectum, liver) that were scanned.
10. Select your preferred surgeon if applicable, choosing from the available options provided in the form.
11. Review the completed form for accuracy. Once finalized, save your changes, download the document, print it out for record-keeping, and share it as needed.

Complete the Canada NYGH Colorectal Cancer Diagnostic Assessment Program Referral Form online today for efficient processing!