C-endo (a division of C-health)6720 – 104 Street NW

Edmonton, AB T6H 2L4Ph: (780) 306-5555 Fx: (780) 431-2554

www.c-health.ca

C-ENDO-ACENTREOFEXCELLENCECOMMITTEDTOCOMPREHENSIVEDIABETESANDENDOCRINOLOGYCARE

DateofReferral:PATIENTINFORMATION(orattachpatientlabel)PatientName:ULI#:Phone:Address:

PostalCode:Gender: Male Female

City,Prov.:

DateofBirth:

RelevantHistory:

ReferringPhysicianSignature:

Fax:ReferringPhysician:Ph:PracticeID:AdditionalReportto:Fax:

PleaseNote:Wewill faxtheappointmentdateandtimetoyouroffice and notify the patient by phoneor letter. The patient may require labs to becompleted prior to this appointment and a labrequisition will also be sent to the patient. Werequire 48-hour notice for cancellation orreschedulingofappointment.

Fortriageofreferralspleasecheckoneofthefollowing:

DIABETESMANAGEMENT

ENDOCRINOLOGISTGENERALINTERNISTNOPREFERENCE,SHORTESTWAITTIME

GENERALENDOCRINOLOGY

THYROIDDISORDER FEMALEREPRODUCTIVEMALEREPRODUCTIVEOSTEOPOROSISCALCIUM/PARATHYROIDBARIATRICMATTERSPITUITARY/ADRENALOTHER

URGENT FIRSTAVAILABLE ROUTINE

Note:Pleaseensurepatientdemographicsarecurrent.