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Generic Referral Date (yyyy-Mon-dd) Refer to Fax Referring provider/source Phone Address Fax Family Physician Guardian/Appointed Agent (if applicable) Patient Guardian Name Phone Relationship Please type directly into the form. Where indicated, required referral information may be attached. Please ensure referral meets specific referral requirements where these are available. 19619(Rev2017-11) Referral Information Reason for referral Type of referral New referral Re-referral 2nd opinion Urgent referral Service/consultant is aware of urgent referral Reason for urgency ____________________________________________________________________________ Specialist seen previously No Yes ▼ If Yes Date seen If Yes Diagnosis Diagnosis Date (yyyy-Mon-dd) Prior hospital admission (past 2 years) No Yes (If yes, when and where?) Currently hospitalized, where? Past Medical History Attached Current Medications/Allergies Attached Requested Action Confirm and/or advise diagnosis Assume future management of patient within area of expertise Confirm and/or advise management, including medication Telephone consultation Assume management for this problem and return patient after care Patient education Processing Requirements (Check if included) Blood work Diagnostic imaging Consultant letters Discharge summaries Microbiology Pathology Factors that may affect consultation/care Specific patient request Physician Location Language Interpreter required Physical limitations Social/Psychological Economic Other For office use only Name Signature Designation Date (yyyy-Mon-dd)

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Page 1: Generic Referral Form - Alberta Health Services · Generic Referral Date (yyyy-Mon-dd) Refer to Fax Referring provider/source Phone Address Fax Family Physician Guardian/Appointed

Generic Referral

Date (yyyy-Mon-dd) Refer to Fax

Referring provider/source Phone

Address Fax

Family Physician

Guardian/Appointed Agent (if applicable)

Patient Guardian Name Phone Relationship

Please type directly into the form. Where indicated, required referral information may be attached. Please ensure referral meets specifi c referral requirements where these are available.

19619(Rev2017-11)

Referral InformationReason for referral

Type of referral New referral Re-referral 2nd opinion Urgent referral Service/consultant is aware of urgent referralReason for urgency ____________________________________________________________________________

Specialist seen previously No Yes ▼If Yes Date seen If Yes Diagnosis Diagnosis Date (yyyy-Mon-dd)

Prior hospital admission (past 2 years) No Yes (If yes, when and where?) Currently hospitalized, where? Past Medical History Attached

Current Medications/Allergies Attached

Requested Action Confi rm and/or advise diagnosis Assume future management of patient within area of expertise Confi rm and/or advise management, including medication Telephone consultation Assume management for this problem and return patient after care Patient educationProcessing Requirements (Check if included)

Blood work Diagnostic imaging Consultant letters Discharge summaries Microbiology PathologyFactors that may affect consultation/careSpecifi c patient request Physician Location Language Interpreter required Physical limitations Social/Psychological Economic Other For offi ce use only

Name Signature Designation Date (yyyy-Mon-dd)

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