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New Patient Referral Form

Due to the current COVID-19 pandemic, hospitals that normally share imaging with the MUHC are no longer able to push their images through.

In order to minimize delays and the number of trips on the patient, KINDLY REQUEST THAT THE PATIENT BRING A CD OF THEIR IMAGING SCANS TO THEIR VISIT.

Medical Consultation

Urgent *

Yes

No

Referring Physician

First Name and Last Name *

Institution and Department *

E-mail Address

Phone Number *

Patient Information

First Name *

Last Name *

RAMQ *

Patient's Phone Number *

Reason for Consult *

Attachments

Please include any relevant diagnostic test results, images, photos or other documentations: CT Chest/Abdomen/Pelvis report, PET Whole Body scan report, Pathology reports (biopsy results), Endoscopy/Gastroscopy report (suspected esophageal or gastric cancers), Pulmonary Function Test (suspected lung cancers), CT Head/MRI Brain (if applicable)

Attachment 1