CArE Referral Form - Centre of Arthritis Excellence CArE

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.

License Required: Enter a valid license key in Settings > Image Marker Settings to use this field.

Indicate the areas of pain/swelling:

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Referring Provider:

Billing Number:

Phone Number:

Fax Number:

Signature

Date