6720 – 104 Street NW Edmonton, AB T6H 2L4 Ph: (780) 306 ...€¦ · general endocrinology thyroid...
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C-endo (a division of C-health) 6720 – 104 Street NW Edmonton, AB T6H 2L4 Ph: (780) 306-5555 Fx: (780) 431-2554 www.c-health.ca C-ENDO - A CENTRE OF EXCELLENCE COMMITTED TO COMPREHENSIVE DIABETES AND ENDOCRINOLOGY CARE Date of Referral: PATIENT INFORMATION (or attach patient label) Patient Name: ULI#: Phone: Address: Postal Code: Gender: Male Female City, Prov.: Date of Birth: Relevant History: Referring Physician Signature: Fax: Referring Physician: Ph: Practice ID: Additional Report to: Fax: Please Note: We will fax the appointment date and time to your office and notify the patient by phone or letter. The patient may require labs to be completed prior to this appointment and a lab requisition will also be sent to the patient. We require 48-hour notice for cancellation or rescheduling of appointment. For triage of referrals please check one of the following: DIABETES MANAGEMENT ENDOCRINOLOGIST GENERAL INTERNIST NO PREFERENCE, SHORTEST WAIT TIME GENERAL ENDOCRINOLOGY THYROID DISORDER FEMALE REPRODUCTIVE MALE REPRODUCTIVE OSTEOPOROSIS CALCIUM / PARATHYROID BARIATRIC MATTERS PITUITARY / ADRENAL OTHER URGENT FIRST AVAILABLE ROUTINE Note: Please ensure patient demographics are current.
Transcript of 6720 – 104 Street NW Edmonton, AB T6H 2L4 Ph: (780) 306 ...€¦ · general endocrinology thyroid...
C-endo (a division of C-health)6720 – 104 Street NW
Edmonton, AB T6H 2L4Ph: (780) 306-5555 Fx: (780) 431-2554
www.c-health.ca
C-ENDO-ACENTREOFEXCELLENCECOMMITTEDTOCOMPREHENSIVEDIABETESANDENDOCRINOLOGYCARE
DateofReferral:PATIENTINFORMATION(orattachpatientlabel)PatientName:ULI#:Phone:Address:
PostalCode:Gender: Male Female
City,Prov.:
DateofBirth:
RelevantHistory:
ReferringPhysicianSignature:
Fax:ReferringPhysician:Ph:PracticeID:AdditionalReportto:Fax:
PleaseNote:Wewill faxtheappointmentdateandtimetoyouroffice and notify the patient by phoneor letter. The patient may require labs to becompleted prior to this appointment and a labrequisition will also be sent to the patient. Werequire 48-hour notice for cancellation orreschedulingofappointment.
Fortriageofreferralspleasecheckoneofthefollowing:
DIABETESMANAGEMENT
ENDOCRINOLOGISTGENERALINTERNISTNOPREFERENCE,SHORTESTWAITTIME
GENERALENDOCRINOLOGY
THYROIDDISORDER FEMALEREPRODUCTIVEMALEREPRODUCTIVEOSTEOPOROSISCALCIUM/PARATHYROIDBARIATRICMATTERSPITUITARY/ADRENALOTHER
URGENT FIRSTAVAILABLE ROUTINE
Note:Pleaseensurepatientdemographicsarecurrent.
