Get Patient Information & Referral Form

Filling out the Patient Information & Referral Form is an important step in ensuring that individuals receive the appropriate medical care. This guide provides you with clear, step-by-step instructions to help you complete the form efficiently online.

Follow the steps to effectively complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the general patient information section. This includes providing the patient’s first and last name, address, city, country, postal/ZIP code, and telephone numbers for home and work.
3. Next, enter the referring physician's information. You will need to include their first and last name, address, city, country, postal/ZIP code, specialty, telephone, and fax numbers along with their email.
4. In the section for reason for consultation, select the appropriate option, such as emergency, confirm a diagnosis, or seek treatment. Indicate if critical care transport is required and whether an interpreter will be needed.
5. Provide patient medical information by detailing the chief complaint or current diagnosis. List any previous examinations, including specifics like X-rays or MRIs, and include past medical history with any relevant details.
6. Make sure to document any drug or food allergies, the patient’s weight in kilograms, and height in centimeters. Include a list of current medications.
7. If applicable, list in which hospitals the patient has been previously hospitalized and the reasons for those stays. Also, enter the tentative date of visit at the hospital and the method of payment.
8. Complete the additional information section, noting who will accompany the patient to the hospital, including their relation to the patient and contact information.
9. Finally, review all entered information for accuracy, save your changes, and download or print the completed form for your records or to share with the appropriate recipients.

Start completing the Patient Information & Referral Form online now to ensure a smooth process.