REFERRAL FOR CONSULTATION

OVERALL_INSTRUCTIONS

Chief Complaint

[Provide detailed description of patient's presenting symptoms]

Template

REFERRAL FOR CONSULTATION DR. B.T. DANG. M.D. 474 College St., Suite 307 Toronto, Ontario M6G 1A4 Tel. 537-5100 & Fax: 537-5800 DATE: [today's date] TO: [specialist's name] RE: [patient name] Date of birth:. [patient's date of birth (YYYY-MM-DD)] OHIP No. : [patient's OHIP number] Referral for: [Specify referral purpose: either assessment and recommendation for management / assessment, or management and return to family physician when condition is stable] Patient's complaint: [Provide detailed description of patient's presenting symptoms] Family physician's assessment: [Provide detailed summary of family physician's clinical assessment and findings] Previous investigation and management: [Provide summary of any previous investigations, test results, treatments, and management plans] Thank you. Sincerely yours, B.T. DANG, M.D OHIP 0000-224923-00.