Download Medical Genetics Referral Form - Editable

Division of Medical Genetics
Department of Pediatrics
Royal University Hospital
Room 515, Ellis Hall,
103 Hospital Drive
Saskatoon SK S7N 0W8 Canada
Telephone: (306) 655-1692
Facsimile: (306) 655-1736
K. Davis
MD, FRCPC
Medical Geneticist
Division of Medical Genetics - Referral Form
Patient information:
J. Lucas
MS, CCGC
Genetic Counsellor
Full Legal Name (Last, First):
Birth/Maiden Name: __________________
M. Paterson
MSc, CCGC, CGC
Genetic Counsellor
PHN:
Date of birth (DD/MM/YY):
If child, parents names:
L. Benoit
MS, CCGC, CGC
Genetic Counsellor
If child is in foster care, name & contact number for social worker:
C. Jackel-Cram
PhD, MSc, CCGC
Genetic Counsellor
Current phone number:
T. Scriver
MS, CCGC, CGC
Genetic Counsellor
Current mailing address:
Home
Work
Cell
Has a family member been seen by Medical Genetics or have a known genetic diagnosis?
If yes, Name:
No
Yes
Relationship:
Name of affected family member, if different from above:
General Referral: All relevant clinical reports and test results must be included with referral.
Reason:
Prenatal Referral: If available, attach all prenatal records and genetic test results.
Reason for referral:
LMP:
EDC:
Cancer Referral: If available, attach relevant clinic notes, pathology reports, screening reports and genetic
test results for patient or affected family member.
Cancer Genetics Intake Referral Form completed or given to patient?
No
Yes
Reason for referral:
Referring Physician Name: (Please print):
Referring Physician Phone Number:
Visit us at https://www.saskatoonhealthregion.ca/locations_services/Services/Medical-Genetics