For more information about specific sections on the form, please click the yellow "Notes" buttons on the left hand side of the page.
Otolaryngology (including Pediatrics)
The existing Otolaryngology SRF is now expanded to include more pediatric indications. This is a drafted form - 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.
Patient Information
Surname:
First:
DOB:
Gender:
HN:
Mobile #:
Home #:
Business #:
Email:
Address:
[Optional] Additional Patient Information
Preferred Name:
Sex assigned at birth:
Pronouns:
Preferred language:
Best method of contact:
Referral Details
Triage Considerations
Requested Priority:*
Concern(s) / Indication(s) Triggering Referral*
Select all that apply:
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
Current Problem List:
Past Medical History:
Current Medications:
Family History:
Allergies:
Supporting Documentation
Please attach all relevant laboratory and diagnostic investigations
+ Add Attachments
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
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Referral Preferences
All patients will be triaged to the shortest wait time unless a preference is entered.
Other considerations: