Medical Genetics Referral Form printable pdf download

Medical Genetics Referral Form

Medical Genetics

Royal University Hospital

Room 515, Ellis Hall,

103 Hospital Drive. Saskatoon SK S7N 0W8

Telephone: (306) 655-1692

Facsimile: (306) 655-1736

Email:

medicalgenetics@saskatoonhealthregion.ca

Division of Medical Genetics

Referral Form

Patient information:

Full Legal Name (Last, First):

Birth/Maiden Name: _______________________

Date of birth (DD/MM/YY):

PHN:

If child, parents names:

If child is in foster care, name & contact number for social worker:

Current mailing address:

Street address, City, Province, Postal Code

Current phone number:

Home

Work

Cell

General Referral: Attach all relevant clinical reports and test results.

Reason:

Prenatal Referral: If available, attach:

 Prenatal Screening results for this pregnancy

 Results of Amniocentesis and/or CVS

 Results of all obstetric ultrasounds for this pregnancy

 Results of previous genetic testing

Reason for referral:

LMP:

EDC:

Cancer Referral: If available, attach:

 Relevant clinical notes

 Pathology reports for all primary site cancers

 All screening reports

 Results of previous genetic testing / family members’ genetic test results

Reason for referral:

--------------------------------------------------------------------------------------------------------------------------------------------------------

Has a family member previously seen Genetics?

Yes

If yes, Name:

Relationship:

Name of affected family member, if different from above:

Referring Physician Name: (Please print):

Medical Genetics Referral Form

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