PCN General Specialist Referral oct 2014

PCN
Specialty & Specialist Referral Form
Urgent Referral?
Yes
□
No
□
Patient Label
Name of Parent/Caregiver: _________________________
Phone____________________
REASON FOR REFERRAL
Specialty (On Site):
Phone: Teresa at 780-410-8053
P
HISTORY & REFERRAL SPECIFICS
□ Cardiology – Edmonton Cardiology Consultants
□ General Surgery – Dr. O. Farooq
Phone: Pat at 780-410-8002
□ Dermatology – Dr. C. Lortie
□ Dermatology – Dr. P. Lee
Phone: Jackie H at 780-410-8055
□ Foot & Ankle – Dr. K. Ravji
□ Orthopedic – Dr. J. Thambiraj
Phone: Jackie C at 780-410-8029
□ Plastic Surgery – Dr. D. Wong
Specialty (Off Site):
□ Allergy
□ Endocrinology
□ Gastroenterology
□ Hematology
□ Internist
□ Cardiology
□ General Surgery
□ Vascular Surgery
□ Dermatology
□ Nephrology
□ Pediatrics
□ Plastic Surgery
□ Respirology
□ Rheumatology
□ Urology
□ Neurology/EMG
□ Neurosurgery
□ Orthopedic Surgery
□ OB/GYN
□ Ophthalmology
□ Otolaryngology
Phone: Sandy at 780-410-8022
Phone: Teresa at 780-410-8053
Phone: Pat at 780-410-8002
Phone: Jackie C at 780-410-8029
Phone: Jackie H at 780-410-8055
Note: psychiatry referrals are on the Mental Health referral form
Phone: Cheryl at 780-410-8051
Referrals that are received without the required
investigations will be returned and not processed until
all information is completed
Fax All Referrals To: 780-416-0139
PHYSICIAN INFORMATION
Referred by (PLEASE PRINT): ___________________________________________________________________________________________________
Date of Referral: ______________________________
Physician SIGNATURE:______________________________________________________
PHONE: _______________________________________
FAX: _________________________________________
Sherwood Park Primary Care Network, 150 Broadway Crescent, Sherwood Park, AB T8H 0V3 Fax: (780) 416-0139
APPOINTMENT DATE & TIME: ________________________________________________
Updated – October 2014

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