Brocade VDX 6720 Hardware Reference Manual VDX6720_HardwareManual
6720 – 104 Street NW Edmonton, AB T6H 2L4 Phone: (780) 306 ... · 6720 – 104 Street NW...
Transcript of 6720 – 104 Street NW Edmonton, AB T6H 2L4 Phone: (780) 306 ... · 6720 – 104 Street NW...
C-endo(adivisionofC-health)6720–104StreetNW
Edmonton,ABT6H2L4Phone:(780)306-5555
Fax:(780)431-2554www.c-health.ca
PleaseNote:Wewillfaxtheappointmentdateandtimetoyourofficeandnotifythepatientbyphoneorletter.Thepatientmayrequirelabstobecompletedpriortothisappointmentandalabrequisitionwillalsobesenttothepatient.Werequire48-hournoticeforcancellationorreschedulingofappointment.
RelevantHistory:ReferringPhysicianSignature:
C-ENDO-ACENTREOFEXCELLENCECOMMITTEDTOCOMPREHENSIVEDIABETESANDENDOCRINOLOGYCARE
DateofReferral:
PATIENTINFORMATION(orattachpatientlabel)
PatientName:
ULI#:
Phone:
Address:
City,Prov.: PostalCode:
DateofBirth: Gender: Male Female DAY/MONTH/YEAR
Fortriageofreferralspleasecheckoneofthefollowing:
DIABETESMANAGEMENT
ENDOCRINOLOGISTGENERALINTERNISTNOPREFERENCE,SHORTESTWAITTIME
GENERALENDOCRINOLOGY
THYROIDDISORDERFEMALEREPRODUCTIVEMALEREPRODUCTIVEOSTEOPOROSISCALCIUM/PARATHYROIDBARIATRICMATTERSPITUITARY/ADRENALOTHER
URGENT FIRSTAVAILABLE ROUTINE
Note:Pleaseensurepatientdemographicsarecurrent.
ReferringPhysician:
Ph: Fax:
PracticeID:
AdditionalReportto:
Fax:
UpdatedApril2016