Patient Referral Form - Dr. Padma Naidu

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Patient Referral Form

Thank you for visiting this site.
Please see the referral form below which can be filled out sent out to us right from here. If you have any questions, feel free to contact me.

REFERRAL REASON FOR CONSULT

DIABETES MANAGEMENT REFERRAL

Specialists & Multi-Disciplinary Team Approach

Type 1 DiabetesType 2 DiabetesUsing Insulin Pump

WEIGHT MANAGEMENT OBESITY

Adults > 18 Years with a BMI between 27 to 30

Please indicate BMI

Adults > 18 Years with a BMI > 30

Please indicate BMI

BMI calculator: www.nhlbi.nih.gov/guidelines/obesity/BMI/bmi-m.htm

AnemiaWeight ManagementChest Pain NYDPre-Operation ConsultantMedical ConsultantIV iron for iron deficiency AnemiaThrombocytopeniaLeukocytosisHematology

REQUESTED ACTION - PLEASE COMPLETE

Confirm and/or advise as to diagnosisSuggest medication or management

Other:

REQUESTED TEST - PLEASE COMPLETE

Body Composition AnalysisExercise Stress TestHolterBone Marrow BiopsyLoop MonitorEKG

Documentation Attached – Blood work, Microbiology, Diagnostic Imaging, Discharge summaries, Pathology

Other:

PATIENT INFORMATION - PLEASE COMPLETE

Last Name

First Name

MaleFemale

Home Address

City

Postal Code:

Home Phone

Date of Birth

OHIP Number:
(Must have valid Ontario Health Card)

Email Address

REFERRING PHYSICIANS INFORMATION - PLEASE COMPLETE

Referring Physician:

Billing Number:

Address:

Backline Number:

Fax Number:

Physician’s Signature Required:

Date of referral

Please Note:
Our office will contact your patient with an appointment date and time.
All consult notes will be sent to your office via fax after each patient visit.

Phone Number (519) 948-8000

Email Support drpnaidu1@gmail.com

- OR -

1720 Howard Avenue,
Suite 164 Windsor, ON N8X 5A6
Phone- 5199488000
Fax - 5199489191