Speech-Language Pathology Services

713, chemin Montréal Road, Ottawa, ON K1K 0T2
Tél./Tel.: 613-746-4621 poste/extension 4105
Téléc./Fax: 613-748-4991
hopitalmontfort.com
Client Name:
Speech-Language
Pathology Services
ADULT REFERRAL FORM
OUTPATIENT
Referral source (name and title):
Please indicate services requested :
Sex : □ M □ F
Birthdate:
Address :
Telephone :
Health Card no:
Contact Person/Relationship:
Telephone :
Physician :
Phone:
 Swallowing
 Communication (caused by an acquired neurological condition)
 Voice Therapy
Medical history (attach all relevant medical documentation such as MRI, CT, Neurology, ENT, or GI
reports):
When were the difficulties first noticed and how frequently do they occur?
Has Speech-Language Pathology been consulted in the past? Please provide details (e.g. name,
location, goals, etc.):
Please describe any swallowing or dietary concerns (e.g. odynophagia, coughing with liquids/
solids, unintended weight loss, etc.):
Please describe concerns with communication (e.g., speech, understanding, reading, writing, etc.):
Please describe concerns with voice and any associated breathing difficulties:
*Physician or Nurse Practitioner signature required:
________________________________________________ Date (dd/mm/yy):__________________
*Please note by signing this referral you are also consenting to a Videofluoroscopic Swallowing
Study, if indicated by clinical exam.
We try to see each client in a timely manner. Please be aware that there is frequently a waiting period due
to the high number of referrals we receive. Failure to complete and return the referral form may result in a
delay to see the client.
Please fax referral to: 613-748-4991
F:\Orthophonie\Services externes à Montfort\Clinique externe pour les troubles de la communication\Formulaire de
référence
Télécopie
Fax
713, chemin Montréal Road, Ottawa, Ontario K1K 0T2
www.hopitalmontfort.com
téléphone/telephone: (613) 746-4621 ext. 4105
télécopieur/facsimile: (613) 748-4991
Nombre de pages (incluant la couverture)
Number of pages (including cover page)
Date :
Destinaire/ To :
Expéditeur/ From :
Orthophonie, La clinique pour les troubles de la communication
Speech-Language Pathology, Communication Disorders Clinic
Tél./Tel.
613-746-4621, poste/ extension 4105
Téléc./ Fax
613-748-4991
Demande pour services en orthophonie
Referral for Speech-Language Pathology services
Message :
Documents inclus :
□
□
□
□
□
□
la requête signée par un médecin;
la raison pour la demande;
le nom, l’adresse, et comment contacter le
patient;
l’histoire médicale complète (rapport
d’admission et de congé);
les rapports récents d’imagerie diagnostique
(MRI, CT, etc.);
Tout autre rapport pertinent (ex : Orthophonie,
Neurologie, ORL, Gastro-entérologue, etc.).
Included documents :
□
□
□
□
□
□
Referral signed by a medical doctor
Reason for consult
Patient name, address, & contact information
Full medical history (admission & discharge
reports)
Recent diagnostic imaging reports (MRI, CT,
etc.)
All other relevant reports (e.g. SpeechLanguage Pathology, Neurology, ENT, GI,
etc.)
CET ENVOI EST DESTINÉ SEULEMENT Ầ LA PERSONNE DÉSIGNÉE ET PEUT CONTENIR DES RENSEIGNEMENTS
CONFIDENTIELS. S’il ne s’adresse pas à vous, ne pas copier, distribuer, ni utiliser les renseignements s’y rapportant. Si vous
avez reçu cette télécopie par erreur, veuillez téléphoner immédiatement à l’expéditeur pour l’en aviser et détruire les
documents. Merci de votre collaboration.
THE DOCUMENTS IN THIS TRANSMISSION ARE DESTINED TO THE AFOREMENTIONED PERSON AND MAY CONTAIN
CONFIDENTIAL INFORMATION INTENDED ONLY FOR THE ADDRESSEE. If this transmission is not addressed to you,
please do not disclose, photocopy, distribute, or take any action in regards to the information. Please notify the sender
immediately by telephone and destroy the documents. Thank you for your collaboration.