PREPROD - CRDS Cardiology Consultation Adult

N/A
N/A	Status : N/A

Note : Refer to the clinical alerts

and favor, if available, the protocols of the Accueil Clinique before filling out this form.

Use this form only for new consultation. If not, the patient should contact their cardiologist's office in order to be seen.

The field «Patient's last name» is required and may not be left blank.The field «Patient's first name» is required and may not be left blank.The field «Health insurance number» is required unless it's absence is justified in the field «Justification absence HIN». Format LLLL99999999 is requiredThe expiration field of the health insurance number must be composed of a valid year and month in the format 9999.The field « Justification absence HIN » is required if the HIN is absent.Date of birth - Invalid format - YYYY-MM-DD, the date must be less than today's dateOne of the fields : «Telephone number 1» or «E-mail» is required. Format required for the field «Telephone no. 1» including the area code = 999-999-9999Telephone extension 1 - Invalid format. Maximum 10 numbers - 9999999999Format required for the field «Telephone no. 2» including the area code = 999-999-9999Telephone extension 2 - Invalid format. Maximum 10 numbers - 9999999999The field «Mother's last name» is required and may not be left blank.The field «Mother's first name» is required and may not be left blank.The field «Address» is required and may not be left blank.The field «City» is required and may not be left blank.Please enter a postal code in the format A9A9A9 or check a reason of absence « Unknown » or « Residing outside of Québec » The patient's e-mail address must contain the « @ » character and be a valid address.

Patient's last name

First name

Health insurance number

Expiration (YYMM)

Justification absence HIN

Date of birth (YYYY-MM-JJ)

Sex

Telephone no. 1

Extension 1

Telephone no. 2

Extension 2

Mother's last name

Mother's first name

Address

City

Absence of postal code

Unknown

Residing outside of Quebec

Postal code

E-mail address

How to contact the patient

Region

Region id

Reason for consultation

Clinical priority scale: A: ≤ 3 days B: ≤ 10 days C: ≤ 28 days D: ≤ 3 months E: ≤ 12 months

Other reason for consultation	Clinical priority
At least one «Reason for consultation» must be selected, otherwise the field «Other consultation reason» must be completed.	The field «Clinical priority» is required if an «Other consultation reason» is entered.

Prerequisite

(Insert all the prerequisites not available in the DSQ)

Holter

Please check only one of the two choices «Results available in the DSQ» or «Prescribed examinations to be performed»

Results available in the DSQ

Prescribed examinations to be performed

Other reports

Suspected diagnosis and clinical information (mandatory)

Special needs

The field «Referring physician's last name » is required and may not be left blank.The field «Referring physician's first name » is required and may not be left blank.The referring physician's «license no.» field is required. Invalid format : It must be composed of 5 to 7 numbers. (99999, 999999 or 9999999)The referring physicians point of service telephone number is required and must have the format : 999-999-9999The referring physicians point of service extension number must be numeric - Invalid format maximun of ten numbers 9999999999The referring physicians point of service fax number is required and must have the format : 999-999-9999

Referring physician identification and point of service
Referring physician's last name		Referring physician's first name
License
Point of service telephone number		Extension
Fax number
Name of point of service *	The field «Name of point of service» is required and may not be left blank.

Family physician

Same as referring physician

Patient with no family physician

The field «Family physician's last name » is required and may not be left blank.The field «Family physician's first name » is required and may not be left blank.The field «Family physician's point of service» is required and may not be left blank.

Family physician's last name
Family physician's first name
Name of point of service

Registered referral (if required)
If you would like a referral for a particular physician or point of service

ReqReg_DateModification

ReqReg_Etat

ReqReg_EtablissementCreateur

ReqReg_Id

ReqReg_IDType

DernierPersonne

DernierDateHeure

regionSociosanitaire

noPermisRefProvider

fichier PDF

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Refer the patient to the Emergency-department

Suspected acute coronary syndrome, angina at rest

Acute decompensated heart failure

Rapid atrial fibrillation ≥ 110 bpm at rest or poorly tolerated

Sudden syncope (without prodrome)

Symptomatic bradycardia with heart rate < 40 bpm or documented daytime > 3 second pauses

Comments

Write the phone number that will allow the Centre de répartition des demandes de services (CRDS) to confirm the appointment.

Write the postal code so an appointment can be made near the patient's residence.

Check off the reason for consultation.

Or write the unexpected reason for consultation in the “Other” section and specify the clinical priority.

Clinical priority

Justify any modified clinical priority or any other reason for consultation.

Allows the CRDS to know the maximum period to realize the appointement. Time limit calculated in calendar days (including holidays and weekends). You will be informed of any priority that cannot be accommodated.

Write down any information justifying the clinical priority or any changes to it.

Forward all necessary consultation prerequisites (reports or analyses) to CRDS.

Attach the medication list.

Special needs: Write down any particular requirements such as an interpreter, wheelchair, etc.

Fill out this section so the consultation report can be sent to you at the correct point of service.

The time limit may not be upheld if the requested physician is not available. The CRDS will contact you to find an alternative solution.

The results are available in the DSQ : check the box « Results are available in the DSQ »

Prescribed examinations to be performed (labs and simple X-Rays) : You must prescribe the examination for the patient and you must check the box « Prescribed examinations to be performed »

Prescribed examinations to be performed (ultrasound, MRI and CT scans) : For ultrasound, MRI and CT scans you must attach the examination request to « Other reports » using the feature in you local DMÉ application

Results are not available in the DSQ : You must insert the results of the examination via the feature in your local DMÉ application before submitting it to CRDS.

Results are not available in the DSQ	Results are available in the DSQ
Electromyography (EMG)	X-Rays
Electroencephalography (EEG)	Laboratory
Visual acuity	Medications
Optometrist report
Eye pressure
Growth curve
Cytology
Pathology
Bone mineral density (BMD)
Bone scintigraphy (SCINTY)