Patient referral form1

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This Telemedicine Patient Referral Form contains fields for a referring physician to provide information about a patient they are referring for an OTN telemedicine consultation, including the patient's name, date of birth, contact details, primary service requested, and reason for referral. The form is to be faxed to OTN Scheduling Services to initiate a telemedicine appointment for the patient.

TELEMEDICINE PATIENT REFERRAL FORM TSM #:
Fax to OTN Scheduling Services - 1.888.879.2807 (internal use only)
Please note: Request form must precede supporting documentation when faxing Print Form
REFERRING PHYSICIAN INFORMATION
Referring Physician Name (First/Last) Work Phone Number (ext) Alternate Phone Number (ext) Fax Number

Street Address City Province Postal Code Referring Physician
is Family Physician
Ontario

Family Physician Name (First/Last) Preferred Patient site for OTN consult (if known) Provincial Billing Number

APPOINTMENT INFORMATION
Primary Service (Specialty) Consultant Name (First/Last) Work Phone Number (ext) Fax Number

Priority Request Time Period Type of Appointment

PATIENT INFORMATION
Patient Name (First/Last) Date of Birth (DDMMYYYY) Age Sex

Home Phone Number Alternate Phone Number Preferred Language Provincial Health Card Number Version Code

Mailing Address City Province Postal Code

Ontario

Contact Preference Alternate Contact Name (First/Last) Home Phone Number Alternate Phone

Special Requirements (patient mobility, oxygen requirements, etc)

REASON FOR REFERRAL
(If consultant is identified, please attach relevant reports including current list of medications)

SIGNATURE OF REFERRING PHYSICIAN DATE
Note: The information contained in this form is confidential. It contains personal health information that is subject to the provisions of the
Personal Health Information Protection Act, 2004. This form and its contents should not be distributed, copied or disclosed to any unauthorized
persons. If you have accessed this form in error, please contact the referring physician or OTN Scheduling at 1.866.454.OTN1 (6861) immediately.

This document outlines the clinical protocol for telemedicine services at an unnamed organization. It includes sections on overview with inclusion and exclusion criteria, referral and scheduling procedures, preparation requirements for patients and the telemedicine studio at both the referring site and specialist site, and procedures for telemedicine sessions including obtaining consent, introducing participants, conducting examinations, making recommendations, and documenting follow-up plans. The protocol aims to standardize telemedicine visits and ensure patient privacy and continuity of care.

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Patient referral form1

1. TELEMEDICINE PATIENT REFERRAL FORM TSM #: Fax to OTN Scheduling Services - 1.888.879.2807 (internal use only) Please note: Request form must precede supporting documentation when faxing Print Form REFERRING PHYSICIAN INFORMATION Referring Physician Name (First/Last) Work Phone Number (ext) Alternate Phone Number (ext) Fax Number Street Address City Province Postal Code Referring Physician is Family Physician Ontario Family Physician Name (First/Last) Preferred Patient site for OTN consult (if known) Provincial Billing Number APPOINTMENT INFORMATION Primary Service (Specialty) Consultant Name (First/Last) Work Phone Number (ext) Fax Number Priority Request Time Period Type of Appointment PATIENT INFORMATION Patient Name (First/Last) Date of Birth (DDMMYYYY) Age Sex Home Phone Number Alternate Phone Number Preferred Language Provincial Health Card Number Version Code Mailing Address City Province Postal Code Ontario Contact Preference Alternate Contact Name (First/Last) Home Phone Number Alternate Phone Special Requirements (patient mobility, oxygen requirements, etc) REASON FOR REFERRAL (If consultant is identified, please attach relevant reports including current list of medications) SIGNATURE OF REFERRING PHYSICIAN DATE Note: The information contained in this form is confidential. It contains personal health information that is subject to the provisions of the Personal Health Information Protection Act, 2004. This form and its contents should not be distributed, copied or disclosed to any unauthorized persons. If you have accessed this form in error, please contact the referring physician or OTN Scheduling at 1.866.454.OTN1 (6861) immediately.

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Patient referral form1

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