Clot Clinic E-Referral for Telehealth Appointment

To Drs Prasad/ Janowski/ Melville/Jane Gordon/Makhija/Rankin/Holmes/Alexander Gordon

First Name

Last Name

Date of Birth

Phone number

Patient Address

Patient e-mail

Clinical Notes

Attach scans/test results/discharge summary

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Attachments mandatory *

ImagingFBC, UEC, LFTDischarge Summary

Doctor's Name *

Provider No. *

Date:

Referrer E-mail

Address:

Send correspondence to GP? *

YesNo

GP Name

Patient is aware of this e-referral and consents to receiving correspondence from Clot Clinic via phone/email

YesNo

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