Get the free Pediatric Clinic Referral Form - Algoma Public Health

Genetic Counselling Clinic Pediatric Referral Form Telephone: (705) 9424646 x3123 Fax: (705) 7595789 294 Willow Avenue Salt Ste. Marie, ON P6B 0A9 Website: www.algomapublichealth.com Date of Referral:

How to fill out pediatric clinic referral form

How to fill out pediatric clinic referral form

1. Gather all necessary information about the patient, including their personal details and medical history.
2. Check if the referral form requires any specific information or documents to be attached.
3. Fill out the patient's demographic information such as name, date of birth, address, contact details, and insurance information.
4. Provide relevant medical history, including previous diagnoses, medications, allergies, and any other pertinent information.
5. Indicate the reason for the referral, specifying the type of specialist or service needed.
6. Include any additional notes or specific instructions for the receiving pediatric clinic.
7. Ensure all information provided is accurate and legible.
8. Submit the completed referral form to the appropriate department or physician's office as instructed.

Who needs pediatric clinic referral form?

1. Parents or guardians of children who require specialized care or consultation from a pediatric specialist.
2. Primary care physicians who need to refer a patient to a pediatric clinic for further evaluation or treatment.
3. Healthcare professionals involved in a child's care who believe a referral to a pediatric clinic is necessary for comprehensive management.
4. Insurance companies or third-party payers who require a referral form to authorize coverage for pediatric specialty services.

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