ISSNHL TREATMENT PATHWAYS


HYPERBARIC OXYGEN THERAPY AND WOUND CARE

ISSNHL Referral Form

    PATIENT INFORMATION

    DATE OF BIRTH

    GENDER

    MEDICAL INFORMATION







    ADDITIONAL ATTACHMENTS

    PLEASE ATTACH THE FOLLWING REPORTS, IF AVAILABLE:

    MRI, CHEST X-RAY, ECG, PFT’s, ECHOCARDIOGRAM, CHEST CT, PAST MEDICAL HISTORY, CURRENT MEDICATION LIST, BLOODWORK INCLUDING CBC, UREA, CREATININE, ELECTROLYTES, CRP, ESR, HbA1c, CARDIOLOGY. PLEASE ONLY SUBMIT WORD OR PDF FILES.

    REFERRER'S INFORMATION

    CLINICIAN TYPE

    CONTACT US

    2009 Long Lake Rd, B1

    Sudbury ON, P3E 6C3