Referral Form General

Referral Form General
Date

MonthDayYear
Referring Doctor's Name

First NameLast Name
Physician PRAC-ID Billing Number
Office Phone Number

Area CodePhone Number
Office Fax Number

Area CodePhone Number
Office Email
example@example.com
PATIENT INFORMATION
Patient Name

First NameLast Name
Patient Alberta Health Card Number
Sex

MaleFemaleOther (please specify)
Date of Birth

MonthDayYear
Date
Patient Phone Number

Area CodePhone Number
Patient Alternate Phone Number

Area CodePhone Number
Patient Address

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
REFERRAL REASON
Please select urgency of referral:

ASAP (Immediately vision threatening)Urgent (Within 72 hours)RoutineSpecial Request (please specify)
Please select reason for referral:

Routine eye examDiabetic retinopathy screeningVision lossRed eye/dry eyePediatric eye examPlaquenil Retinal ToxicityMyopia ManagementOther (please specify)
Please provide additional relevant referral information: (optional)
Please provide additional relevant referral information: (optional)
Please upload any images or files here (e.g. pictures, PDF documents, EMR generated referral doc, etc.) (optional)

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Please upload any additional files here (e.g. pictures, PDF documents, etc.) (optional)

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Referrals can still be faxed if you wish to 587 324 2825
Should be Empty:

PATIENT INFORMATION