Nephrology

This is a draft standardized eReferral form for Nephrology. Final design may differ.
The form is designed to be viewed on a computer.

For more information about specific sections on the form, please click the yellow "Notes" buttons on the left hand side of the page.

Patient Information

Surname:

First:

DOB:

Gender:

Male

Female

Other

HN:

Mobile #:

Home #:

Business #:

Email:

Address:

* Indicates a required field

Lab Values

Serum creatinine, urinalysis and urine ACR strongly recommended for all referrals.

Consider renal ultrasound if risk of obstruction or unexplained acute worsening of renal function.

Labs Attached Separately

eGFR:

Date:

Creatinine:

Date:

Urine ACR:

Date:

Hematuria (dipstick):

HbA1c:

Hemoglobin:

Potassium:

Calcium:

Phosphate:

Albumin:

Cumulative Patient Profile

Please delete any sensitive information you do not intend to share from the CPP

CPP attached separately (if not entered below)

Current Problem List:

Past Medical History:

Current Medications:

Family History:

Allergies:

Preferred Consultant or Location

All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered.

Preferred consultant or location

Patient willing to travel for shorter wait time

Other considerations:

Supporting Documentation

Please attach all relevant laboratory and diagnostic investigations.

Personal Health Information that is medically relevant has not been disclosed at the request of the patient.

+ Add Attachments

Referrer's Information

Site Name:

Address:

City:

Province:

Postal Code:

Phone:

Fax:

Billing #:

Professional ID:

Signed:

Role:

Thank you for taking time to review this form.
Ontario Health & eHealth Centre of Excellence

Notes

Urgency

Referrals are considered routine by default
“Urgent Referral” checbox should be used to indicate when a patient needs urgent care.
If a referral is marked as urgent, then a “Reason for Urgency” must be provided to explain why.
Note that the consulted provider will still triage the referral urgency based on the information provided.

Concerns and Indications

This list is intended to:

Facilitate referral form completion by providing the most common reasons for referral
Facilitate specialist triaging by improving referral clarity
Allow for addition of clinical guidance (where applicable)
Allow for specific follow up questions to assist triage (where applicable)
Allow eReferral platforms to identify which providers accept referrals for specific conditions since specialists may remove concerns and indications they do not see.

This list is not meant to be a comprehensive list of all conditions within a specialty, and an “Other” option is provided
A generic referral form is available that uses free-text instead of a list for specialists that prefer this option.

Brief Description

This mandatory field is meant to describe the relevant patient information, which may include the current history, management, investigations, or expectations of the referral.

Notes