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Interventional pain management
Stellate Ganglion Block
Ophthalmology
Maxillofacial and oral surgery
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Plastic and reconstructive surgery
Therapeutic plasma exchange
General surgery
Vasectomy
News
SGB Referral Form
We thank you for your referral, please complete the form below.
Provider Information
First Name
*
Last Name
*
Phone Number
*
Email Address
*
Address
*
Provider No.
*
Patient Information
First Name
*
Last Name
*
Address
*
Phone
*
Email Address
*
Date of Birth
*
Medicare No.
*
IDV.
*
Expiry
*
Gender
*
Male
Female
Other
Height (CM)
Weight (KG)
Medications
*
Diagnosis/Indication of Treatment
Primary Diagnosis
*
Clinical Indication
*
(check all that apply)
Complex regional pain syndrome (CRPS) affecting the upper limb
Certain neuropathic pain conditions of the head, neck, or arm
Circulatory disorders such as Raynaud’s phenomenon
Some connective tissue or vascular conditions affecting blood flow
Other
Please specify
Relevant clinical history
*
Attachments
Please attach any disgnostics, imaging or pathology reports relevant to this referral.
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