(INCOMPLETE REFERRALS WILL BE RETURNED FOR COMPELETION) • completed intake form to: (416) 867-3736 •Fax will contact you and your patient with appointment date and time •We note the booking process can take up to two weeks. •Please AVAILABLE ONLINE: www.stmichaelshospital.com REFERRAL DATE: REQUESTED CLINIC: (Please select below) General Pediatric Clinic Developmental Clinic Adolescent Clinic □ □ □ FASD Clinic Hematology Clinic Neonatal Follow-up clinic □ □ □ Special Nutrition Clinic Antenatal Clinic Cardiology Clinic □ □ □ Newcomer to Canada Clinic Dermatology Clinic □ □ PATIENT INFORMATION PLEASE IF URGENT MRN # _ REFERRING PHYSICIAN Last Name: First: Referring Physician (please print) / Billing # D.O.B. dd/mm/yyyy Age: Address: Address City: Prov: Postal: Telephone # / Fax # Contact #: OHIP #: IFH # __________________________________ Previously Seen in this clinic: Yes No ◌ ◌ INSURANCE #: ________________________ AGE CATEGORY (PLEASE CIRCLE) NEWBORN INFANT PRESCHOOL CHILD ADOLESCENT 0-3 MOS 3 12 MOS 12-36 MOS 3 12 YEARS 13-18 YEARS – – NO YES if yes language ________________________________ -Language Interpreter Required? □ □ – NO YES -American Sign Language Interpreter Required? □ □ NO YES - Does the patient have a regular family doctor? □ □ -Newcomer NO YES to Canada Clinic: Has patient been in Canada for less than 2 years? □ □ Social Work Dietitian Other services: _________________ - Indicate all services already involved: □ □ □ REASON FOR REFERRAL PLEASE SEND: ALL PERTINENT DIAGNOSTIC & LAB RESULTS LIST OF CURRENT MEDICATIONS INVESTIGATIONS • • CONSULT NOTES / DISCHARGE SUMMARY GROWTH CHART PREVIOUS RESOURCES • • •
• (INCOMPLETE REFERRALS WILL BE RETURNED FOR COMPELETION) •Fax completed intake form to: (416) 867-3736 •We will contact you and your patient with appointment date and time •Please note the booking process can take up to two weeks. AVAILABLE ONLINE: www.stmichaelshospital.com REFERRAL DATE: REQUESTED CLINIC: (Please select below) General Pediatric Clinic □ Developmental Clinic □ Adolescent Clinic □ FASD Clinic □ Hematology Clinic □ Neonatal Follow-up clinic □ Special Nutrition Clinic □ Antenatal Clinic □ Cardiology Clinic □ Newcomer to Canada Clinic □ Dermatology Clinic □ PATIENT INFORMATION PLEASE IF URGENT MRN # _ Last Name: First: D.O.B. dd/mm/yyyy Age: Address: City: Prov: Postal: Contact #: OHIP #: IFH # __________________________________ INSURANCE #: ________________________ REFERRING PHYSICIAN Referring Physician (please print) / Billing # Address Telephone # / Fax # Previously Seen in this clinic: Yes ◌ No ◌ AGE CATEGORY (PLEASE CIRCLE) NEWBORN 0-3 MOS INFANT 3 – 12 MOS PRESCHOOL 12-36 MOS CHILD 3 – 12 YEARS ADOLESCENT 13-18 YEARS -Language Interpreter Required? □ NO □ YES – if yes language ________________________________ -American Sign Language Interpreter Required? □ NO □ YES - Does the patient have a regular family doctor? □ NO □ YES -Newcomer to Canada Clinic: Has patient been in Canada for less than 2 years? □ NO □ YES - Indicate all services already involved: □ Social Work □ Dietitian □ Other services: _________________ REASON FOR REFERRAL PLEASE SEND: ALL PERTINENT DIAGNOSTIC & LAB RESULTS • LIST OF CURRENT MEDICATIONS • INVESTIGATIONS • CONSULT NOTES / DISCHARGE SUMMARY • GROWTH CHART • PREVIOUS RESOURCES
pediatric-intake-form.docx