Get the free Concussion Clinic Referral Form - CHEO - Home

Concussion Clinic Referral Form To be completed by Physician Please FAX to 613 2603897 Patient Information *(Please complete all fields) Name: Gender: Male Female DOB (DD/MM/YYY): Address: City: Province:

How to fill out concussion clinic referral form

How to fill out a concussion clinic referral form:

1. Start by carefully reading through the form instructions. Familiarize yourself with the required information and any specific guidelines mentioned.
2. Fill in your personal details accurately, such as your full name, date of birth, address, and contact information. This is important for the clinic to reach out to you if necessary.
3. Provide your medical history, including any previous diagnoses, treatments, or surgeries related to concussions or head injuries. Be thorough and include dates if possible.
4. Specify the reason for seeking a referral to a concussion clinic. Describe your symptoms, how long you have been experiencing them, and any events that may have led to the concussion.
5. If applicable, include the contact information of the healthcare professional who initially examined or diagnosed your concussion. This may include their name, clinic or hospital details, and the date of the examination.
6. Check if there are any additional documents or test results that need to be attached to the referral form. This might include imaging results (such as CT scans or MRI) or any other relevant medical reports.
7. Ensure that you sign and date the form in the designated section. Your signature confirms that the information provided is accurate and that you give consent for the referral to the concussion clinic.
8. Once the form is completed, follow the submission instructions provided. This may involve sending it electronically, mailing it, or taking it directly to the clinic.

Who needs a concussion clinic referral form?

1. Individuals who have experienced a head injury or a suspected concussion.
2. Patients who exhibit symptoms associated with concussions, such as headaches, dizziness, memory problems, difficulty concentrating, or changes in behavior.
3. Athletes who have suffered a head injury during sports activities, including contact sports like football, soccer, or boxing.
4. Individuals involved in accidents, falls, or incidents that resulted in a blow to the head.
5. Anyone seeking specialized evaluation, diagnosis, and treatment for concussion-related injuries or symptoms that have not resolved with initial medical care.

For pdfFiller’s FAQs

What is concussion clinic referral form?

The concussion clinic referral form is a document used to refer patients with concussions to specialized clinics for treatment and care.

Who is required to file concussion clinic referral form?

Medical professionals, including doctors and nurses, are required to file the concussion clinic referral form when referring a patient to a concussion clinic.

How to fill out concussion clinic referral form?

The concussion clinic referral form typically requires information about the patient's medical history, symptoms, and the reason for referral. It should be filled out accurately and completely by the referring medical professional.

What is the purpose of concussion clinic referral form?

The purpose of the concussion clinic referral form is to ensure that patients with concussions receive the appropriate care and treatment from specialized clinics.

What information must be reported on concussion clinic referral form?

The concussion clinic referral form may require information such as the patient's name, date of birth, medical history, symptoms, and the referring medical professional's contact information.

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