Request for consultation

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Patient information

First name

Last name

Date of birth (YYYY-MM-DD)

Email

Phone #

Health card # (AAAA 0000 0000)

Address

City

Postal code (A0A 0A0)

Reason for consultation

Where has the pain/symptoms been the worse?

Arm

Back

Leg

Neck

Knee

Hip

Shoulder

I confirm that patient does not have any emergent RED FLAGS.

RED FLAGS (Please refer patient directly to the closest Emergency!): • Possible Cauda Equina Syndrome • Loss of anal sphincter tone/ fecal incontinence • Saddle anaesthesia about anus, perineum, or genitals • Urinary retention with overflow incontinence • Progressive neurologic deficit • Significant traumaRED FLAGS (Please refer patient to his family doctor !): •Constitutional symptoms (fever, chills) • Unexplained weight loss • Night sweats • History of cancer • Pain worsening at night or at rest • Immunosuppression • IV drug use • Recent bacterial infection

Clinical information (medication, comorbidities, etc.)

Referring doctor

First name

Last name

Licence # (5 digits)

Email

Phone #

Extension #

Practice location

Fax #

Postal code (A0A 0A0)

I hereby refer the above noted patient to CareChain and diagnostics and physician specialists as appropriate. I read and agree to the Website terms of use, Privacy policy and Plain language description of security safeguards.

Relevant document(s) (e.g. imaging)

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REQUEST FOR CONSULTATION

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