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Ministry Form 1 Application by Physician for of Mental Health …

WEB6427–41 (2000/12) Queen’s Printer for Ontario, 2000 7530–4972 (Disponible en version française) 5. Given the person’s history of mental disorder and current mental or …

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URL: https://londonreferral.files.wordpress.com/2017/12/form-1-and-42.pdf

HURON PERTH SENIORS MENTAL HEALTH & ADDICTION …

WEBPATIENT: Page 1 of 4 Revised 17/02/14 HURON PERTH SENIORS MENTAL HEALTH & ADDICTION RESPONSE TEAM Community Mental Health Services Box 309, 28 …

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Osteoporosis and bone disease program referral form

WEBOsteoporosis and bone disease program referral form. Osteoporosis and Bone Disease Program. 268 Grosvenor St. London, ON N6A 4L6 Phone: 519-646-6000 ext. 64434 …

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Victoria Hospital, Urgent Medicine Clinic Other Associated …

WEBVictoria Hospital, Urgent Medicine Clinic Other Associated Appointments: Zone E – 5th Floor 519-685-8500 ext 58745 Type of Appointment: Name: Date: Appointment Date: Time:

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4.13 Diagnostic Codes

WEBClaims Submission Resource Manual for Physicians October 2015 4 - 37 Version 2.0 Traumatic: 716 : Arthrogryposis (Contracture of Joint) 728 Asbestosis 501

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BREAST ASSESSMENT REQUEST FORM

WEBBREAST ASSESSMENT REQUEST FORM St. Joseph’s Health Care London F: 519-646-6204 DATE OF BOOKED EXAM:_____ PATIENT INFORMATION Surname …

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MRI REQUISITION – this form can be found on www.swpca …

WEB☐ Huron Perth Health Care Alliance - Stratford F: 519-272-8247 ☐ St. Joseph's Health Care London F: 519-646-6025

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Referral Form- Pregnancy Options Program

WEBReferral Form- Pregnancy Options Program Women’s Health Care Centre Rm B5-372 (Pod 5) Office Use Only LHSC Victoria Hospital Date Received: _____ 800 Commissioners …

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HIV and HTLVI/HTLVII Serology HIV PCR Test Requisition

WEBTitle: HIV and HTLVI/HTLVII Serology HIV PCR Test Requisition Author: Public Health Ontario Subject: HIV and HTLVI/HTLVII Serology HIV PCR Test Requisition

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LONDON SPECIALISTS GROUP

WEBLONDON SPECIALISTS GROUP ~ A division of Medpoint Health Care ~ 233-355 Wellington St. (CitiPlaza), London, Ontario N6A 3N7 • Phone: 519 432-1919 • …

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(Emergency)) Hematology Referral General Number

WEBHematology Referral Please Fax to 519-685-8294 Date _____ Patient Demographics Referring Physician Benign Urgent ~ Fax and Call physician’s office General Hematology

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CYTOLOGY & HPV TESTING REQUISITION

WEBCYTOLOGY & HPV TESTING REQUISITION GYNECOLOGIC CYTOLOGY (PAP TEST) HPV TESTING HPV testing can be ordered, at the patient’s request, on the same …

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Common Billing Codes 2015

WEBA002 n o18 Month Developmental Assessment 62.20 K017 Child Periodic Health Visit 2 to 15 years - no diagnostic code needed 43.60 K130 Adolescent Periodic Health Visit 16 …

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Request for Orthopaedic Consultation

WEBX-RAY REPORTS OF THE AFFECTED JOINT MUST ACCOMPANY REFERRAL. If no X-ray report is available from within the last 6 months, we recommend the following views: …

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RABIES REPORT FORM

WEB- 2 - INVESTIGATION NOTES: (please date and sign each entry) February 13, 2014 G:\WPFiles\FORMS\RABIES\Rabies Report form – rev February 13, 2014 TREATMENT …

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Fax completed form back to 519-667-6766

WEBZone E Level 5 Room E5-211 Baseline Rd Entrance turn left - Victoria Hospital, LHSC Parking Lot 7 Telephone (519) 667-6661 or 685-8500 x 77681. Fax completed form …

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KMH-IHICardiologyConsult FEB 14 2018 VERSION 2

WEBFax Completed form to 905-855-1863 or 1-877-564 -3297 2. See back for patient instructions and map. CONSULT CONSULT, IF TEST RESULT IS …

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Anticoagulation Clinic (AC) at UH Referral Form

WEBNote: Anticoagulation for non-cardioembolic indications should be referred to the Thrombosis Clinic at LHSC Victoria Hospital. PLEASE ATTACH ALL relevant …

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