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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 |
| Outpatient Specialized Geriatric Services Referral Form | RHC 2697 | English |
| Stroke Prevention Clinic Referral Form | RHC 3100 | English |
| Nipissing District Paramedic Services Referral for Community Paramedic Home Visit | RHC 3159 | English |
| Heart Failure Clinic Referral Form | RHC 3248 | 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 |
| Patient Consent for Data Sharing with Cloud Based Insulin Pump and Glucose Software Applications | RHC 3175 | English |
| 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
Sudbury
680 Kirkwood Drive,
Sudbury, ON
P3E 1X3
Tel: 705-675-9193
Fax: 705-675-6817
