CArE Referral Form - Centre of Arthritis Excellence CArE

Patient Information

Name(Required)

First Last

Date of Birth(Required)

Age

Gender

Address(Required)

Street Address City Postal Code

Phone Number(Required)

Health Card Number(Required)

(include version code)

Reason for Referral/Clinical Question

Is participation in daily activities impacted by illness?

Yes

Duration of symptoms:

<6 mos

6-12 mos

Years (#)

If Years, how many?

Past Medical History

(Please attach additional pages as needed, incl. bloodwork and imaging)

Current Medications

(Please attach list/additional pages as needed)

Family History of Inflammatory/Auto-Immune Condition (i.e. Psoriasis, IBD, RA)

Yes

Please list any accommodations required for this patient to receive care

(i.e. mobility device, service animal, communication support)

NOTE: Please attach copies of imaging reports, any relevant consultations, treatments and surgical notes.

Max. file size: 2 MB.

Indicate the areas of pain/swelling:

Click or tap the image to place a mark. Using a keyboard: press Tab to focus the image, use the arrow keys to move the crosshair, hold Shift for finer steps, and press Enter or Space to place a mark.

Referring Provider:

Billing Number:

Phone Number:

Fax Number:

Signature

Date