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Patient Information
Confirm, Reschedule, Cancel
Results
Referral Forms3

Patient Information

Patient Information

Home
Patient Information
Confirm, Reschedule, Cancel
Results
Referral Forms3

Home
Patient Information
Confirm, Reschedule, Cancel
Results
Referral Forms3

Rheumatology, Immunology

& Allergy Referral Form

Download Form as PDF

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- Step 1 of 2

Date of Referral *

Patient Name *

First

Last

Email *

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone Number *

Health Card Number *

Referring Physician/NP

Billing Number

Family Physician Name

Physician Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Physician Phone

Physician Fax

Physician Email

Referral Please Family

Suspected Diagnosis

Emergent? *

Yes. e.g. Vasculitis, Giant Cell Arteritis, Organ-Threatening Connective Tissue Disease
No

Autoimune/Inflamatory

Connective Tissue Disease
Polymyalgia Rheumatica
Non-emergent Vasculitis
Auto-inflammatory Disease
Gout/ Pseudogout

Immunodeficiency

Recurrent Infections

Example: igQ, (G.A.M.E.)

Allergy

Environmental Testing (Rhinitis, Rhinosinutis, Asthma)
Suspected Food Allergy
Urticaria

Please provide any additional information below. (i.e. possible allergens, possible reactions)

Lab Tests, Diagnostic Imaging, Investigations and Other Recommendations

Lab Tests, Diagnostic Imaging, Investigations and Other Recommendations

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The Waterside Clinic

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79 Colborne Street E. Orillia, ON L3V 1T5

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Office Hours

Monday: 9am – 4pm
Tuesday: 9am – 4pm
Wednesday: 9am – 4pm
Thursday: 9am – 4pm

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705-734-3943