Medical Clinic/Program Forms

Referral Forms

Name

Number

Language

Consent for Release of Personal Health Information RHC 164 English
Anticoagulation Clinic Referral Form RHC 790 English
Pulmonary Function Referral Form RHC 1140 English
Therapeutic Diet Counselling Referral RHC 1172 English
Pain Management Clinic Questionnaire RHC 1579 English
Pain Management Consultation Request RHC 1867 English
Chronic Obstructive Pulmonary Disease (COPD) Referral RHC 2210 English
Medical Referral for Adult Diabetes Education RHC 2293 English
Pain Management Clinic Consultation Checklist RHC 2675 English
Geriatric Community Outreach Paramedicine Referral Form RHC 3094 English
Stroke Prevention Clinic Referral Form RHC 3100 English
Nipissing District Paramedic Services Referral for Community Paramedic Home Visit RHC 3159 English

 

Patient Information Forms

Name

Number

Language

Orthopaedic Clinic Patient Information RHC 280 English
Total Knee Arthroplasty – Patient Plan of Care RHC 756 English
Iron Infusion Medication Information and Discharge Instructions RHC 1886 English
Pre-Op Hip Class RHC 2109 English & French
Pre-Op Knee Class RHC 2110 English & French
Sotrovimab (Monoclonal Antibody) Infusion Patient Information RHC 3186 English
Pain Management Patient Information No RHC # English
Pain Management Clinic Map/Directions No RHC # English

 

Other Forms

Name

Number

Language

History and Physical Exam RHC 340 English
Telemedicine Dermatology Consult RHC 2367 English
Ophthalmology Clinic Physician Appointment (Dr. Vijay) RHC 2835 English
Final MAID Consent Waiver RHC 3109 English
How to book & obtain IV iron for the treatment of Anemia RHC 3119 English

North Bay

50 College Drive,
P.O. Box 2500
North Bay, ON
P1B 5A4
Tel: 705-474-8600

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Sudbury

680 Kirkwood Drive,
Sudbury, ON
P3E 1X3
Tel: 705-675-9193
Fax: 705-675-6817

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Floor Plans

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Visitors Guide

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