I NTERNATIONAL P ATIENT P ROGRAM - R EFERRAL F ORM

555 University Avenue Room 7251, Black Wing Toronto, ON M5G 1X8 Tel: 416-813-7680 Fax: 416-813-8667 website: www.sickkids.ca/internationalprogram

PART 2 **MUST BE COMPLETED BY THE REFERRING SPECIALIST**

Patient Name: Country: Date of Birth: Height: Weight:

Vaccinations (to date) : Allergies: Dental Report/Status: Previous test / procedures or hospitalization & reasons: Exposure to infectious diseases: (ie Tuberculosis, etc) Purpose of referral to Sick Kids: Second Opinion Surgical Treatment Medical Treatment

State Patients Primary and Secondary (if applicable) Diagnoses:

Date of Diagnosis: Is the proposed treatment: Urgent No Acute Yes (please specify): Elective

Is this patient currently on medication?:

What professional services are following this patient? (example: physiotherapy, dietary)

Is post-operative or follow-up care available in this patients home country? Please propose a time frame in which this patient requires treatment:

Yes 4-6 months

No 6-12 months

Your signature below will indicate that all post-operative and follow-up care for this patient, upon discharge from The Hospital for Sick Children, will be your responsibility.

Physician's Signature

Date (yyyy/mm/dd)

Physician's Stamp

April 28, 2010

International Patient Program Referral Form (Part 2) Please note: This application is not for distribution

1 of 2

I NTERNATIONAL P ATIENT P ROGRAM - R EFERRAL F ORM

555 University Avenue Room 7251, Black Wing Toronto, ON M5G 1X8 Tel: 416-813-7680 Fax: 416-813-8667 website: www.sickkids.ca/internationalprogram

PART 2 **MUST BE COMPLETED BY THE REFERRING SPECIALIST**

Patient Name:

Date of Birth: REFERRING SPECIALIST INFORMATION Physician Name and Specialty: Practice Address:

City/Province:

Postal Code:

Country:

Telephone: Email Address: How long have you known this patient?

Fax:

SUPPORTING DOCUMENTATION FOR PATIENT REFERRAL

IMPORTANT: SickKids Hospital requires that the patients referring specialist verify the special circumstances that necessitate a referral outside of the applicants home country. Documentation must be provided that the assessment, procedure, surgery and/or treatment is not available in the home country; therefore, necessitating a referral aboard (i.e. inadequate treatment options, specialized expertise). In addition, confirmation all options have been explored in the home country ( Please attach any relevant supporting documentation).

Your signature below will indicate that all post-operative and follow-up care for this patient, upon discharge from The Hospital for Sick Children, will be your responsibility.

Physician's Signature

Date (yyyy/mm/dd)

Physician's Stamp

April 28, 2010

International Patient Program Referral Form (Part 2) Please note: This application is not for distribution

2 of 2