Otolaryngology

This is a draft standardized eReferral form for Otolaryngology. Final design may differ.
The form is designed to be viewed on a computer.

For more information about specific sections on the form, please click the yellow "Notes" buttons on the left hand side of the page.

Patient Information

Surname:

First:

DOB:

Gender:

Male

Female

Other

HN:

Mobile #:

Home #:

Business #:

Email:

Address:

* Indicates a required field

[Optional] Additional Patient Information

Sex assigned at birth:

Female

Male

Intersex

Unknown

Pronouns:

He/Him

She/Her

They/Them

Other

Preferred name

Preferred language:

English

French

Other

Best method of contact:

Mobile

Home

Business

Email

Alternate contact

Unsafe contact persons (do not speak with)

Accessibility concerns or disability

Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)

Send copies of reports to additional providers

Referral Details

Requested Priority:*

Routine

Urgent

Reason for urgent triage: *

Second Opinion

Reason for second opinion:

Concern(s) / Indication(s) Triggering Referral *

Select all that apply:

Ear and Hearing

Cerumen Impaction

Eustachian Tube Dysfunction

Hearing Loss - Sudden / Unilateral

Otitis Externa

Otitis Media

Tinnitus

Vertigo or Dizziness

Other

Facial Plastics & Reconstruction

Head, Neck and Thyroid (Malignancy, Masses, Nodules, or Cysts)

Nasopharyngeal Lesions

Oropharyngeal Lesions

Parathyroid Cyst, Nodule, or Mass

Salivary Gland Mass

Skin Cancer

Thyroid Cyst, Nodule, or Mass

Other

Nose and Sinus

Anosmia or Hyposmia

Deviated Nasal Septum

Epistaxis

Foreign Body Removal

Nasal Polyps

Rhinitis or Sinusitis - Chronic

Other

Throat and Oral Cavity

Other

Specify: *

Brief Description of History, Management, and Investigations *

Cumulative Patient Profile

Please delete any sensitive information you do not intend to share from the CPP

CPP attached separately (if not entered below)

Current Problem List:

Past Medical History:

Current Medications:

Family History:

Allergies:

Preferred Consultant or Location

All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered.

Preferred consultant or location

Patient willing to travel for shorter wait time

Other considerations:

Supporting Documentation

Please attach all relevant laboratory and diagnostic investigations.

Personal Health Information that is medically relevant has not been disclosed at the request of the patient.

Referrer's Information

Site Name:

Address:

City:

Province:

Postal Code:

Phone:

Fax:

Billing #:

Professional ID:

Signed:

Role:

Notes

Overview

This form referral form is intended for Consultations in community and hospital settings
Formatting and style is intended to be consistent across all specialties to reduce cognitive loads
The number of mandatory fields is limited to reduce administrative burdens.

X

Notes

Patient Information

These fields are auto-populated when referral is initiated from an integrated Electronic Medical Record (EMR) or Hospital Information System (HIS).

X

Notes

Additional Patient Information

This section is optional for referrers to complete
Referring providers should use their judgement to determine if any of these fields should be completed. Some fields will auto-complete if launched from an integrated EMR or HIS.

X

Notes

Urgency

Referrals are considered routine by default
“Urgent Referral” checbox should be used to indicate when a patient needs urgent care.
If a referral is marked as urgent, then a “Reason for Urgency” must be provided to explain why.
Note that the consulted provider will still triage the referral urgency based on the information provided.

X

Concerns and Indications

This list is intended to:

Facilitate referral form completion by providing the most common reasons for referral
Facilitate specialist triaging by improving referral clarity
Allow for addition of clinical guidance (where applicable)
Allow for specific follow up questions to assist triage (where applicable)
Allow eReferral platforms to identify which providers accept referrals for specific conditions since specialists may remove concerns and indications they do not see.

This list is not meant to be a comprehensive list of all conditions within a specialty, and an “Other” option is provided
A generic referral form is available that uses free-text instead of a list for specialists that prefer this option.

X

Brief Description

This mandatory field is meant to describe the relevant patient information, which may include the current history, management, investigations, or expectations of the referral.

X

Notes

Cumulative Patient Profile (CPP)

This section auto-populates when referral is initiated from an integrated Eletronic Medical Record (EMR) or Hospital Information System (HIS)
Selecting “CPP attached separately” will hide this section.

X

Notes

Preferred Consultant or Location

This section will only be displayed for group practices or central intakes

X

Notes

Referrer’s Information

Will automatically populate with the referring provider’s information.

X

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Ontario Health & eHealth Centre of Excellence

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