Physiatry Referral Form.pdf

The Alberta Neurologic Centre (ANC) referral form details information for a patient in need of physical medicine and rehabilitation services. Key data includes:

- Patient Details: Name, date of birth, unique ID, address, phone numbers, and insurance policy number.
- Referring Physician: Includes name, practice ID, contact information, and signature.
- Priority Level: Urgent or routine, with a note for urgent cases explaining the urgency.
- Reason for Referral: Options include spasticity/tone assessment, dystonia, ultrasound-guided injection, bracing/orthotics, acute MSK/adult sport injury, or other specific conditions.
- Relevant History and Examination: This section encompasses previous investigations, imaging studies, consults, prior EMG studies, and any other pertinent information.

Upon completion, the referral form is to be faxed to ANC at 587-747-5616. The form is signed by the referring physician and includes contact details for both the referring physician and the intended recipient of copies.