Consultation Referral Form

Dr. Pooja Kharbanda, MD, ABIM

Internal Medicine & Nephrology

Hale Medical Centre | 6-875 Main Street E, Milton, ON L9T 3Z3

Tel: 905-693-0090 / 0040 | Fax: 905-875-0005

Ocean eReferral: Search “HALEMEDICALCENTRE”

Patient Information

Name

Health Card #

Version Code

DOB (DD/MM/YY)

Gender

Phone (Primary)

Phone (Secondary)

Address

Reason for Referral

Nephrology Chronic Kidney Disease (CKD) Management Hypertension (Resistant/Secondary) Proteinuria / Hematuria Investigation Electrolyte Abnormality Nephrolithiasis (Medical management)

Other:

General Internal Medicine Complex Multi-system Assessment Diagnostic Challenge / Undifferentiated Symptoms

Other:

Referring Physician Information

Physician Name

Billing Number

Phone

Fax

Signature & Date