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Name: Fillable Online Lead Extraction Referral Form Fax Email Print - pdfFiller
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Referral to:LHC ARRHYTHMIA SERVICE 339 Winder mere Road, London ON N6A 5A5 Telephone: 5196633746 / Fax: 5196633782 DATE OF REFERRAL: (YYY/MM/DD)IN PATIENTEST PATIENTPATIENT NAME:HT: ___ cm WT: ___

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How to fill out lead extraction referral form

01

Obtain the lead extraction referral form from the appropriate department or provider.

02

Fill out the patient's personal information accurately, including name, date of birth, and contact information.

03

Provide details about the reason for the lead extraction procedure, including any relevant medical history or symptoms.

04

Fill out the referring provider's information, including name, contact information, and signature.

05

Double-check the form for accuracy and completeness before submitting it to the appropriate department or provider.

Who needs lead extraction referral form?

01

Patients who require a lead extraction procedure may need to fill out a lead extraction referral form.

02

Referring providers who are recommending a patient for a lead extraction procedure may also need to fill out this form.

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What is lead extraction referral form?

Lead extraction referral form is a document used to refer a patient for lead extraction procedure.

Who is required to file lead extraction referral form?

The referring physician or healthcare provider is required to file the lead extraction referral form.

How to fill out lead extraction referral form?

To fill out the lead extraction referral form, the referring provider must provide patient information, reason for referral, and any relevant medical history.

What is the purpose of lead extraction referral form?

The purpose of lead extraction referral form is to facilitate the referral process for lead extraction procedure.

What information must be reported on lead extraction referral form?

The lead extraction referral form must include patient demographics, medical history, reason for referral, and referring provider information.

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