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Initial Medical Referral Form: Rehabilitation Mobile App
To get a medical referral, a patient must meet with a health care provider, such as a primary care physician or a physician's assistant. The referral specialist will then take care of any remaining items needed to get the patient to the referred facility.
The Initial Medical Referral Form mobile app helps capture patient information needed to direct him/her to the appropriate facility. The medical referral form contains information on the applicant, diagnosis, injury, treatment and space for additional notes.
The Initial Medical Referral Form is an easy-to-use mobile app that can be completed from any desktop or mobile device. This is a great way to make sure all information is properly collected for patient to move to the next medical center.
Whether you work in administration for referral services or are a referral specialist, you can move patient transfers along more quickly with this convenient app.
Health Care & Social Services mobile forms and apps for your team
Convert your inefficient paper Patient Records and other forms to mobile versions with GoCanvas.
Take a peek inside the Initial Medical Referral Form: Rehabilitation Mobile App
Included Features
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Included Fields
Customize to add, remove, or edit any of the fields below.
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Name
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Title
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Date
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Applicant Information
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Client Name
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Address
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City
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Province
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Postal Code
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Home Phone
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Other Phone
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Date of Birth
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Health Card Number
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Gender
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Emergency Contact Information
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Emergency Contact Name
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Emergency Contact Phone
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Primary Physician Name
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Primary Physician Phone
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Primary Diagnosis
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Secondary Diagnosis
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Imaging
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Need for Isolation?
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Isolation Type
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Brief Current Medical History
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Reason for Admission
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Was a Motor Vehicle Accident Involved?
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Insurance Company Name
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...and More!
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More Information
- Creator: SpeedThought
- Language: English
- Country: United States of America
- Type: Patient Records
- Categories:
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