№ files_lp_4_process_1_43364
Medical referral form issued by the University Health Network Department of Plastic & Reconstructive Surgery for submitting patient information and clinical details for breast reconstruction consultation in Toronto.
Organization: University Health Network
Department: Department of Plastic & Reconstructive Surgery
Document Type: Medical referral form
Institution Address: 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
Fax: 416-340-4403
Region / City: Toronto, Ontario, Canada
Medical Specialty: Plastic and Reconstructive Surgery
Clinical Focus: Breast reconstruction
Purpose: Referral for consultation regarding breast reconstruction procedures
Consulting Surgeons: Dr. Stefan Hofer; Dr. Toni Zhong; Dr. Anne O’Neill; Dr. Siba Haykal
Patient Information Fields: Name; Date of Birth; Health Card Number; Telephone; Address
Clinical Information Required: Breast history, diagnosis, consultation notes, imaging reports
Diagnostic Materials: X-ray; CT; MRI; Ultrasound; Pathology; Operative notes
Consultation Reasons: Immediate breast reconstruction; delayed breast reconstruction; revision surgery; partial breast reconstruction; second opinion
Additional Services Referenced: Medical Oncology; Radiation Oncology; Surgical Oncology
Interpreter Services: Optional, patient primary language specification
Authorizing Party: Referring consultant physician
Approval Method: Consultant name and signature
Price: 8 / 10 USD
The file will be delivered to the email address provided at checkout within 12 hours.

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