Post on 12-Jul-2020
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Early Pregnancy Management Clinic
Form No. 74242 Rev.Oct03_2019
Referral Date:
Patient Demographics: Referring Physician:
Last Name: First Name: Name (print):
Address (print):
Telephone:
Fax:
Billing#: ________________________________________
Birth Date: SMH MRN (J#):
Primary Phone No.: ( )
Alternate Phone No.: ( )
OHIP No.: Relevant History
Clinical Information
Age______ Gravity/Parity ___________
Previous pregnancy loss: c Yes Total previous _____________
c No
INDICATION FOR REFERRAL:
c Management of early pregnancy loss
c Management of retained products of conception
c Unsuccessful medical therapy of pregnancy loss
c Surgical management of pregnancy loss
c Post ER visit for pregnancy loss follow-up
c Pregnancy of unknown location
c First trimester bleeding
For patients to receive an appointment, please ensure ALL of the following results/reports are attached with your referral:
1) Serum bHCG (all values)
2) Blood Group & Screen
3) Transvaginal Ultrasound ( all reports)
If patient is Rh negative, did she receive Rhogam
c Yes Date received: ______________________
c No
Urgency: Within: c 48hrs c 1week c 2 weeks
PLEASE NOTIFY YOUR PATIENT OF THE APPOINTMENT DETAILS
Appointment Date: ________________________ Time: ________________________
Referral not accepted due to incomplete documentation Fax back to referring physician c Yes
Date: _________________________
Early Pregnancy Management Clinic (First Trimester Pregnancy Clinic) – REFERRAL FORM Address: 61 Queen Street East, 5th Floor
PHONE: 416-864-5384 FAX: 416-864-6073 Email: epm@smh.ca
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