Medical Genetics Clinic General Referral Form Instructions

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This form contains 56 fields organized into 10 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Clinical Question and Rationale
Clinical Question and Rationale Text
Provide the specific clinical question and the rationale for the consultation.
Parental familial variant testing reports Checkbox
Check this box if you are providing parental familial variant testing reports to support variant interpretation. Fill only if 'Care Need - Variant Interpretation' is 'Yes'.
Depends on: Care Need - Variant Interpretation
Contact Person
Contact Person Relationship Text
Please specify the relationship of the contact person to the patient.
Contact Person Name Text
Please provide the full name of the contact person if they are not the patient.
Contact Person Telephone Text
Please provide the telephone number for the contact person.
Diagnosis in family Checkbox
Check this box when including a diagnosis in the patient’s family.
Describe how affected person(s) are related to your patient Checkbox
Check this box when describing how affected family members are related to the patient.
Echocardiogram Checkbox
Check this box if you are including an echocardiogram report with the referral.
Family History
Diagnosis in Family Text
Please describe the diagnosis found within the family.
Affected Person Relationship Text
Please describe how the affected person(s) are related to the patient.
General
Clinical Question and Rationale - Line 1 Text
Clinical Question and Rationale - Line 2 Text
Clinical Question and Rationale - Line 3 Text
Clinical Question and Rationale - Line 4 Text
Other Doctor
Other Doctor Billing Number Text
Please provide the billing number for the other doctor.
Other Doctor Address Text
Please provide the full mailing address for the other doctor.
Other Doctor Phone Number Text
Please provide the phone number for the other doctor.
Other Doctor Fax Number Text
Please provide the fax number for the other doctor.
Other Doctor Name Text
Please provide the full name of the other doctor.
Other Relevant Family Member
Other Relevant Family Member Relation Text
Please specify the relationship of this relevant family member to the patient.
Other Relevant Family Member Name Text
Please provide the full name of the other relevant family member.
Other Relevant Family Member Phone Text
Please provide the telephone number of the other relevant family member.
Ophthalmology Consultation Notes Checkbox
Check this box if you are including ophthalmology consultation notes as supporting documentation.
Marfan Syndrome Systemic Score Checkbox
Check this box if you are including the systemic score for possible Marfan syndrome (see marfan.org/dx) with the referral.
Completed developmental assessments (including psychoeducational testing, autism assessments, and/or other) Checkbox
Check this box if you are attaching completed developmental assessments to support the neurodevelopmental referral, including psychoeducational testing, autism assessments, or other evaluations.
Patient Details
Patient Name Text
Please enter the patient's full name, including last and first names.
Patient PHN Text
Please provide the patient's Personal Health Number (PHN).
Patient Date of Birth Date
Please enter the patient's date of birth.
Patient Email Address Text
Please provide the patient's email address.
Patient Home Address Text
Please enter the patient's full home address.
Patient Postal Code Text
Please enter the patient's postal code.
Patient Primary Telephone Text
Please enter the patient's primary telephone number. Fill only if 'Primary Tel Cel' is 'Yes'.
Depends on: Primary Tel Cel
Patient Alternate Telephone Text
Please enter the patient's alternate telephone number. Fill only if 'Alt Tel Work' is 'Yes'.
Depends on: Alt Tel Work
Primary Tel Cel Checkbox
Check this box if the primary telephone number provided is a cell phone.
Alt Tel Home Checkbox
Check this box if the alternate telephone number provided is a home phone.
Alt Tel Cel Checkbox
Check this box if the alternate telephone number provided is a cell phone.
Alt Tel Work Checkbox
Check this box if the alternate telephone number provided is a work phone.
Care Need - Diagnosis Checkbox
Check this box if the predominant care need for the patient is related to diagnosis.
Care Need - Variant Interpretation Checkbox
Check this box if the predominant care need for the patient is related to variant interpretation.
Care Need - Management Checkbox
Check this box if the predominant care need for the patient is related to management.
Care Need - Family Implications/Planning Checkbox
Check this box if the predominant care need for the patient is related to family implications or planning.
Required Info - Relevant Consultation Notes Checkbox
Check this box to indicate that relevant consultation notes are included as required information for the patient.
Required Info - Results from Completed Genetic Testing Checkbox
Check this box to indicate that results from completed genetic testing are included as required information for the patient.
Required Info - Relevant Investigations Checkbox
Check this box to indicate that relevant investigations (e.g., imaging) are included as required information for the patient.
Predominant Care Need
Confirmation that parental testing will not be available Checkbox
Check this box if confirmation that parental testing will not be available is provided. Fill only if 'Care Need - Variant Interpretation' is 'Yes'.
Depends on: Care Need - Variant Interpretation
Provide relevant records with a completed Release of Information consent form for affected family members Checkbox
Check this box when you are including relevant records along with a completed Release of Information consent form for the affected family members.
Referral Details
Referral Date Date
Please enter the date the referral was made.
Interpreter Language Text
Please provide the language required for an interpreter, if applicable.
Patient Aware of Referral Checkbox
Check this box to confirm that the patient is aware of this referral.
Primary Phone Type: Home Checkbox
Check this box if the primary telephone number provided is a home phone number.
Primary Phone Type: Cell Checkbox
Check this box if the primary telephone number provided is a cell phone number.
Referring Doctor
Referring Doctor Text
Enter the name of the referring doctor or clinic.
Referring Doctor Billing Number Text
Provide the billing number for the referring doctor or clinic.
Referring Doctor Address Text
Enter the full address of the referring doctor or clinic.
Referring Doctor Phone Number Text
Provide the primary phone number for the referring doctor or clinic.
Referring Doctor Fax Number Text
Provide the fax number for the referring doctor or clinic.