C-endo (a division of C-health) Suite 240, 1016 - 68 Avenue SW Calgary, AB T2V 4J2 PH: (403) 705-3636 FAX: (403) 705-2636 www.c-health.ca C-ENDO - A CENTRE OF EXCELLENCE COMMITTED TO COMPREHENSIVE DIABETES AND ENDOCRINOLOGY CARE Date of Referral: PATIENT INFORMATION (or attach patient label) Patient Name: ULI#: Phone: Address: Postal Code: Gender: Male Female City, Prov.: Date of Birth: Relevant History: Referring Physician Signature: Fax: Referring Physician: Ph: Practice ID: Additional Report to: Fax: Please Note: We will fax the appointment date and time to your office and notify the patient by phone or letter. The patient may require labs to be completed prior to this appointment and a lab requisition will also be sent to the patient. We require 48-hour notice for cancellation or rescheduling of appointment. For triage of referrals please check one of the following: DIABETES MANAGEMENT ENDOCRINOLOGIST GENERAL INTERNIST NO PREFERENCE, SHORTEST WAIT TIME GENERAL ENDOCRINOLOGY THYROID DISORDER FEMALE REPRODUCTIVE MALE REPRODUCTIVE OSTEOPOROSIS CALCIUM / PARATHYROID BARIATRIC MATTERS PITUITARY / ADRENAL OTHER URGENT FIRST AVAILABLE ROUTINE Note: Please ensure patient demographics are current.

Suite 240, 1016 - 68 Avenue SW Calgary, AB T2V 4J2 PH ... · PDF fileC -health Global best practices - Applied locally. GeragŽ Cardiometabolic Evaluation and Risk Assessment

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Page 1: Suite 240, 1016 - 68 Avenue SW Calgary, AB T2V 4J2 PH ... · PDF fileC -health Global best practices - Applied locally. GeragŽ Cardiometabolic Evaluation and Risk Assessment

C-endo (a division of C-health)Suite 240, 1016 - 68 Avenue SW

Calgary, AB T2V 4J2PH: (403) 705-3636 FAX: (403) 705-2636

www.c-health.ca

C-ENDO-ACENTREOFEXCELLENCECOMMITTEDTOCOMPREHENSIVEDIABETESANDENDOCRINOLOGYCARE

DateofReferral:PATIENTINFORMATION(orattachpatientlabel)PatientName:ULI#:Phone:Address:

PostalCode:Gender: Male Female

City,Prov.:

DateofBirth:

RelevantHistory:

ReferringPhysicianSignature:

Fax:ReferringPhysician:Ph:PracticeID:AdditionalReportto:Fax:

PleaseNote:Wewill faxtheappointmentdateandtimetoyouroffice and notify the patient by phoneor letter. The patient may require labs to becompleted prior to this appointment and a labrequisition will also be sent to the patient. Werequire 48-hour notice for cancellation orreschedulingofappointment.

Fortriageofreferralspleasecheckoneofthefollowing:

DIABETESMANAGEMENT

ENDOCRINOLOGISTGENERALINTERNISTNOPREFERENCE,SHORTESTWAITTIME

GENERALENDOCRINOLOGY

THYROIDDISORDER FEMALEREPRODUCTIVEMALEREPRODUCTIVEOSTEOPOROSISCALCIUM/PARATHYROIDBARIATRICMATTERSPITUITARY/ADRENALOTHER

URGENT FIRSTAVAILABLE ROUTINE

Note:Pleaseensurepatientdemographicsarecurrent.