Neurosurgery

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Ontario Health & Amplify Care

Referrer's Information

Site Name:

Address:

City:

Province:

Postal Code:

Phone:

Fax:

Billing #:

Professional ID:

Signed:

Role:

Personal Health Information that is medically relevant has not been disclosed at the request of the patient.

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Supporting Documentation

All referrals must include imaging dated within the past

12 months

Preferred Surgeon or Location

All patients will be triaged to the shortest wait time unless a preferred surgeon or location is entered.

Preferred surgeon or location

Patient willing to travel for shorter wait time

Other considerations:

Cumulative Patient Profile

Please delete any sensitive information you do not intend to share from the CPP

CPP attached separately (if not entered below)

Current Problem List:

Past Medical History:

Current Medications:

Family History:

Allergies:

Patient Information

Surname:

First:

DOB:

Gender:

Male

Female

Other

HN:

Mobile #:

Home #:

Business #:

Email:

Address:

Neurosurgery

This is a standardized eReferral form for Neurosurgery.
The form is designed to be viewed on a computer.

For more information about specific sections on the form, please click the yellow "Notes" buttons on the left hand side of the page.

Notes

Requested Priority

Referral form will have "Routine" selected by default
"Urgent" should be used to indicate when a patient needs urgent care
If a referral is marked as urgent, then a "Reason for Urgency" must be provided to explain why
Note that the consulted provider will still triage the referral based on the information provided

Concerns and Indications

This list is intended to:

Facilitate referral form completion by providing the most common reasons for referral
Facilitate specialist triaging by improving referral clarity
Allow for addition of clinical guidance (where applicable)
Allow for specific follow up questions to assist triage (where applicable)
Allow eReferral platforms to identify which providers accept referrals for specific conditions since specialists may remove concerns and indications they do not see.

This list is not meant to be a comprehensive list of all conditions within a specialty, and an “Other” option is provided
A generic referral form is available that uses free-text instead of a list for specialists that prefer this option.

Clinical Question and Narrative

This mandatory field is meant for the referrer to communicate the clinical question or expectations for the referral along with relevant patient information, which may include history, management and investigations

Notes