Rh Prevention Program Of Hamilton Referral Form
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1Rh Prevention Program of Hamilton
Stonechurch Family Health Centre
1475 Upper Ottawa Street
Hamilton, ON L8W 3J6
Phone: (905) 575-0108
Fax: (905) 575-0859
Referral Form
Date of referral _______/ _______/ ________
DD /
MM
/
YY
Patient Information:
Name:
___________________________
DOB:
_______/ _______/ ________
DD /
MM
/
YY
Address:
___________________________
___________________________
Postal Code
____________
Telephone:
( _______) __________________
HNON:
___________________________ Version: _________
Family Physician :
Name:
___________________________
Address:
___________________________
Telephone:
____________________ Fax: ____________________
Physician / Midwife providing antenatal care (if different from above):
Name:
___________________________
Address:
___________________________
Telephone:
____________________ Fax: ____________________
Expected Date of Delivery:
_______/ _______/ ________
DD /
MM
/
YY
Hospital for Delivery:
___________________________
ABO / Rh (please enclose copy of result)
___________________________
Please enroll the above-named patient in the Rh Prevention Program
. (The clinic will
provide the patient with an injection of Rh Immune Globulin that will help prevent the possibility of
the patient developing an allo anti-D antibody, which has been implicated in the development of
HDN (Hemolytic Disease of the New Born)). Please check most appropriate category:
!
Routine 28 week injection of WinRho
!
Emergency injection of WinRho following potentially sensitizing event during pregnancy
(NB: also requires telephone consultation with clinic to ensure patient is clinically
appropriate, and appointment available within best practice timelines. Please also
forward relevant clinical notes / ultrasound results etc.)
___________________________
___________________________
Name – referring practitioner
Signature – referring practitioner
You can download copies of this form at :
IMPORTANT NOTICE: The Rh Prevention Program of Hamilton will not enroll a patient without a completed referral form. An
appointment time will be confirmed with referring practitioner and patient. Drop-in visits without an arranged appointment will not
be accommodated under any circumstances.
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