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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, 5 th Floor PHONE: 416-864-5384 FAX: 416-864-6073 Email: [email protected] CONFIDENTIALITY NOTICE: This message is intended only for the use of the individual or entity to which it is addressed and my contain information that is privileged, confidential, and exempt from disclosure under applicable law. If you are not the intended recipient, please contact the sender and destroy all copies of the original.
