Vascular Surgery

This is a draft standardized eReferral form for Vascular Surgery. Final design may differ.
Please provide your feedback in the form on the right-hand side

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

Referral Details

Clinical Alerts (Non-Exhaustive List)

Direct patient to the closest Emergency Department if:

• Symptomatic aneurysms

• Acute arterial dissection

• Symptomatic carotid stenosis

• Acute limb ischemia

• Dialysis access/AV fistula with complications (e.g. acute bleeding, skin necrosis)

Requested Time to be Seen

Requested Priority:*

Routine (within 12 months)

Non-Urgent (within 2-4 weeks)

Urgent (48 hours to 2 weeks)

Second Opinion

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

Select all that apply:

Aneurysm / Dissection - Asymptomatic

Carotid Stenosis - Asymptomatic

Diabetic Foot Ulcers

Peripheral Arterial Disease

Venous Disease

Varicose Veins with complication

Important Information to Assist Triage

Select all that apply:

Active or healed ulcer

Acute superficial venous thrombophlebitis or bleeding

Venous hypertensive skin changes

Clinical Guidance

• Include lower extremity venous duplex ultrasound

• Recommend compression if no contraindications

Varicose Veins without complication

Upper Extremity Venous Disease

Other

Clinical Question / Goal(s) of Referral with Relevant 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:

[Optional] Additional Patient Information

Sex assigned at birth:

Female

Male

Intersex

Unknown

Pronouns:

He/Him

She/Her

They/Them

Other

Preferred language:

English

French

Other

Best method of contact:

Mobile

Home

Business

Email

Preferred name

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

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.

+ Add Attachments

This button is just for demonstration

Referrer's Information

Site Name:

Address:

City:

Province:

Postal Code:

Phone:

Fax:

Billing #:

Professional ID:

Signed:

Role:

Thank you for taking time to review this form.
Ontario Health & Amplify Care

Notes

Requested Priority

Referral form will have "Routine" selected by default
"Urgent" 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 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

Clinical Question and Narrative

This mandatory field is meant for the referrer to communicate the clinical question or expectations for the referral along with relevant patient information, which may include history, management and investigations

X

Notes

Overview

This referral form is intented to be used by any of the 21 Ontario Hospitals with a Designated Vascular Program
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

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

Referrer’s Information

Will automatically populate with the referring provider’s information.

X

OK

This form is interactable.

Please feel free to click on checkboxes

to see all the options available.

Please click confirm to return to the form.

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