Outpatient Neuro-Palliative Referral Form and Fax Cover Sheet

Outpatient Neuro-Palliative Referral Form and Fax Cover Sheet Please use this fax cover sheet together with the Outpatient Neuro-Palliative Referral Form. [...] • Please ensure you have included the following with your referral: - Physician/NP Signature - Copies of consultations - Copies of diagnostics - Diagnosis and reason for the outpatient Neuro-Palliative Referral Fax Date: To: Outpatient Ambulatory Clinics, Unity Health Toronto - Providence Healthcare Fax: 416-285-3764 From: Phone: Re: Referral to Outpatient Neuro-Palliative Care Clinic Pages (inclu. [...] This facsimile may contain privileged and/or confidential information and is intended for use only by the individual to whom it is specifically addressed. [...] Any distribution, copying or disclosure is strictly prohibited without the written consent of the sender. [...] If you are not the intended recipient or have received this message in error, please notify the sender immediately and destroy this document.