Menopause Clinic Referral FormReferring providers can make referrals using our online referral form. ELIGIBILITY CRITERIA * Funding is currently for patients and providers in Huron-Perth. Patient resides in Huron-Perth Provider is located in Huron-Perth REFERRING PROVIDER INFORMATION * Designation Physician (or physician assistant) Nurse Practitioner Self Referring Provider Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Fax Number * (###) ### #### PATIENT INFORMATION First Name Last Name Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Health Card Number and Version Code * Email * Phone * (###) ### #### Periods * This helps us understand where the patient is in the menopausal transition. Pattern or flow changes but < 1 year since last period > 1 year since FMP Unsure of last period and amenorrheic due to intervention (IUD, continuous birth control, surgery) Patient is unsure of last period (please ask patient to start period tracking) None of the above/Other Symptoms * This helps us understand where the patient is in the menopausal transition. Hot flashes or night sweats (can be persistent or on/off) New vaginal dryness, pain New/worsening bladder issues or incontinence Patient is bothered by symptoms Seeking the midlife women's health review (has symptoms but not bothered by them) Seeking a review of current therapy Other When did the patient's symptoms of the menopausal transition start? * MM DD YYYY Patient's goals of care for the consultation * (i.e. understand symptoms and treatment options, menopause hormone therapy discussion, midlife health review, non-hormonal counselling. Please note that although weight is briefly discussed, the clinic does not offer weight management counselling, medications, or treatment.) Other Pertinent Information * pertinent medical history, consults, etc. The patient has previously had: * If the referral is accepted we will kindly ask you to forward the most recent reports to us when we notify of the acceptance. Lipid profile Pap smear Mammogram Bone Mineral Density Test Pelvic ultrasound in the last 5 years Gynecology Consult in the last 5 years None of the above Thank you for your submission. We will be in touch shortly.
