Canada Island Health Atrial Fibrillation Clinic Referral Form 2019-2025 free printable template
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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...
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How to fill out Canada Island Health Atrial Fibrillation Clinic Referral
01
Obtain the Canada Island Health Atrial Fibrillation Clinic Referral form from your healthcare provider or download it from the official website.
02
Fill in the patient's personal information, including name, date of birth, and contact details.
03
Provide the referring physician's details including name, contact number, and address.
04
Document the patient's medical history relevant to atrial fibrillation, including any previous treatments or medications taken.
05
Indicate the specific symptoms the patient is experiencing that warrant a referral to the clinic.
06
Attach any necessary test results or documentation that support the referral request.
07
Review the information for completeness and accuracy.
08
Sign and date the referral form.
09
Submit the completed referral form to the Canada Island Health Atrial Fibrillation Clinic as instructed.
Who needs Canada Island Health Atrial Fibrillation Clinic Referral?
01
Individuals diagnosed with atrial fibrillation who require specialist assessment and management.
02
Patients experiencing symptoms such as palpitations, irregular heartbeats, or shortness of breath.
03
Persons with a history of stroke or transient ischemic attacks (TIAs) related to atrial fibrillation.
04
Patients for whom current management of atrial fibrillation is ineffective or who are seeking a second opinion.
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What is Canada Island Health Atrial Fibrillation Clinic Referral?
The Canada Island Health Atrial Fibrillation Clinic Referral is a formal request for patients experiencing atrial fibrillation to receive specialized care and assessment at the clinic.
Who is required to file Canada Island Health Atrial Fibrillation Clinic Referral?
Referrals are typically required from primary care physicians or specialists who identify patients with atrial fibrillation that need further evaluation or management.
How to fill out Canada Island Health Atrial Fibrillation Clinic Referral?
To fill out the referral, the referring physician should complete the required referral form, providing necessary patient information, medical history, and reason for referral.
What is the purpose of Canada Island Health Atrial Fibrillation Clinic Referral?
The purpose of the referral is to facilitate access to specialized care, ensuring patients with atrial fibrillation receive appropriate evaluation, treatment options, and management.
What information must be reported on Canada Island Health Atrial Fibrillation Clinic Referral?
The referral must include patient demographics, medical history, current medications, reason for referral, and any relevant diagnostic test results.
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