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Health Record #: ___Complete or place barcoded patient label here Patient Name: (Print first, last)___ DOB: ___/___/___dd mm yy581 Davis Drive, Medical Arts Building Newmarket, ON L3Y 359Age: ___q
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Obtain a copy of the sl169708-lung-diagnostic-assessment-program-referralpdf form.
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Fill out the patient's personal information including name, date of birth, and contact details.
03
Provide information about the referring healthcare provider including name, contact information, and provider number.
04
Specify the reason for the referral and any relevant medical history.
05
Include any supporting documentation or test results that may be relevant to the referral.
06
Review the completed form for accuracy and completeness before submitting it.
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Submit the filled out sl169708-lung-diagnostic-assessment-program-referralpdf form to the appropriate medical facility or healthcare provider.

Who needs sl169708-lung-diagnostic-assessment-program-referralpdf?

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Patients who require a diagnostic assessment for lung-related conditions.
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Healthcare providers who are referring patients for specialized lung evaluations or treatments.
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sl169708-lung-diagnostic-assessment-program-referralpdf is a form used for referring patients to a lung diagnostic assessment program.
Healthcare providers, physicians, or other medical professionals are required to file sl169708-lung-diagnostic-assessment-program-referralpdf when referring patients.
To fill out sl169708-lung-diagnostic-assessment-program-referralpdf, the healthcare provider must provide patient information, medical history, and reason for the referral.
The purpose of sl169708-lung-diagnostic-assessment-program-referralpdf is to facilitate the referral process for patients needing a lung diagnostic assessment.
Patient's name, contact information, medical history, reason for referral, and any relevant test results must be reported on sl169708-lung-diagnostic-assessment-program-referralpdf.
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