Canada Island Health Atrial Fibrillation Clinic Referral Form 2014 free printable template

Atrial Fibrillation Clinic Name Royal Jubilee Hospital 1952 Bay Street Royal Block 3rd Floor Rm 343 Victoria B.C. V8R 1J8 Phone 250-370-8632 FAX NUMBER 250-595-1000 via Western Cardiology DOB M/F PHN MRN Address Telephone number REFERRAL FORM PLEASE NOTE ECG DOCUMENTATION OF AF IS REQUIRED Date Referring physician/NP please print Total pages Referred from Primary care Internist ED Other Please provide the following history AF diagnosis Check one Newly diagnosed Previously diagnosed...

How to fill out Canada Island Health Atrial Fibrillation Clinic

How to fill out Canada Island Health Atrial Fibrillation Clinic Referral

1. Obtain the Canada Island Health Atrial Fibrillation Clinic Referral form from your healthcare provider or download it from the official website.
2. Fill in patient details including full name, date of birth, and contact information in the designated fields.
3. Provide the reason for referral, indicating any relevant medical history related to atrial fibrillation.
4. Include the referring physician's information, including their name, contact number, and any pertinent details.
5. Indicate any previous treatments or interventions already undertaken for atrial fibrillation.
6. Complete any required checkboxes or sections regarding patient symptoms and health status.
7. Sign and date the form to confirm the authenticity of the referral.
8. Submit the completed referral form to the Atrial Fibrillation Clinic via mail, fax, or through the healthcare provider.

Who needs Canada Island Health Atrial Fibrillation Clinic Referral?

1. Patients experiencing symptoms of atrial fibrillation such as palpitations, shortness of breath, or dizziness.
2. Individuals diagnosed with atrial fibrillation who require specialized evaluation or treatment.
3. Patients with a history of heart disease or stroke who may be at risk for atrial fibrillation.
4. Those recommended for referral by their primary care physician during routine check-ups.

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What is Canada Island Health Atrial Fibrillation Clinic Referral?

The Canada Island Health Atrial Fibrillation Clinic Referral is a process through which healthcare providers refer patients to a specialized clinic that focuses on the diagnosis and management of atrial fibrillation, a type of irregular heartbeat.

Who is required to file Canada Island Health Atrial Fibrillation Clinic Referral?

Healthcare providers such as family physicians, cardiologists, and other licensed medical personnel who encounter patients with symptoms or diagnosis of atrial fibrillation are required to file this referral.

How to fill out Canada Island Health Atrial Fibrillation Clinic Referral?

To fill out the Canada Island Health Atrial Fibrillation Clinic Referral, providers should include patient information such as demographics, medical history, current medications, specific symptoms related to atrial fibrillation, and any previous interventions or treatments.

What is the purpose of Canada Island Health Atrial Fibrillation Clinic Referral?

The purpose of the Canada Island Health Atrial Fibrillation Clinic Referral is to ensure that patients receive specialized care for atrial fibrillation, including diagnostics, treatment options, and ongoing management of their condition.

What information must be reported on Canada Island Health Atrial Fibrillation Clinic Referral?

The referral must report essential information such as the patient's name, date of birth, relevant medical history, diagnosis of atrial fibrillation, current treatment plan, and any additional observations that may assist the clinic in providing the best care.