Referral Form
Patient
Last name
First name
Date of birth (YYYY-MM-DD)
Personal health number
Phone (primary)
Phone (alternate)
Address
Province / country of residence
- Interpreter required (language: ___________________)
- Patient resides outside Alberta or outside Canada
- Patient requests information on privately funded consultation
Referring physician
Name
Clinic
Phone
Fax
Family physician (if different)
Family physician fax
Reason for referral
Diagnosis / clinical question
Urgency
- Routine
- Semi-urgent
- Urgent (please also call)
Hernia type (if known)
- Inguinal / groin
- Umbilical / epigastric
- Incisional / ventral
- Recurrent
- Parastomal
- Diastasis recti
- Fistula / complex wound
- Other: __________
Relevant history
- Previous hernia repair
- Mesh in place
- Stoma
- Open wound / infection
- Diabetes
- Smoking / nicotine use
- Anticoagulant / antiplatelet
- Immunosuppression / steroids
Height / weight / BMI
Number of prior repairs
Date of last repair
Records attached
- Current medication list
- Relevant past medical and surgical history
- CT abdomen/pelvis report
- Ultrasound report
- Previous operative notes (incl. mesh type)
- Discharge summaries
- Wound care / home care notes
- Stoma / appliance notes
- Specialist letters
- Imaging location (facility): ____________________
Notes
Additional information
Referring physician signature
Date
Imaging is not required before referral for straightforward groin or umbilical hernias. For recurrent, infected-mesh, parastomal, fistula, or loss-of-domain cases, operative notes and CT imaging allow the fastest review. Referrals are triaged by clinical urgency and complexity.