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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.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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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.

  • Ico textbox

    Name

  • Ico textbox

    Title

  • Ico date

    Date

  • Ico statictext

    Applicant Information

  • Ico textbox

    Client Name

  • Ico textbox

    Address

  • Ico textbox

    City

  • Ico textbox

    Province

  • Ico textbox

    Postal Code

  • Ico textbox

    Home Phone

  • Ico textbox

    Other Phone

  • Ico date

    Date of Birth

  • Ico textbox

    Health Card Number

  • Ico dropdown

    Gender

  • Ico statictext

    Emergency Contact Information

  • Ico textbox

    Emergency Contact Name

  • Ico textbox

    Emergency Contact Phone

  • Ico textbox

    Primary Physician Name

  • Ico textbox

    Primary Physician Phone

  • Ico textbox

    Primary Diagnosis

  • Ico textbox

    Secondary Diagnosis

  • Ico dropdown

    Imaging

  • Ico checkbox

    Need for Isolation?

  • Ico textbox

    Isolation Type

  • Ico multiline

    Brief Current Medical History

  • Ico textbox

    Reason for Admission

  • Ico dropdown

    Was a Motor Vehicle Accident Involved?

  • Ico textbox

    Insurance Company Name

  • ...and More!

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