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Specialist referral form

SPECIALIST'S REFERRAL FORM 2025

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The document is a Specialist's Referral Form from Citizenship and Immigration Canada, used for referring individuals for medical assessments. It requires details about the individual, including identity verification, clinical findings, diagnosis, treatment recommendations, and prognosis. The form must be completed by a specialist and returned to the referring panel physician.

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Click ‘Get Form’ to open the SPECIALIST'S REFERRAL FORM in the editor.
Begin by filling in the identity document details. Indicate if an identity document was seen and provide the UMI number, IME number, and UCI number if applicable.
Enter the date of completion in the format YYYY-MM-DD, followed by the individual's gender, given name, family name, and date of birth.
In the 'Referred to' section, input the specialist's name and address. Clearly state the reason for referral.
Detail what your report will include: clinical findings, diagnosis, pathology report (if available), treatment recommendations, prognosis for five years, and copies of diagnostic tests.
Complete the 'Referred by' section with your name and address as the panel physician.
Finally, ensure you sign and date the declaration confirming that you have examined the client and that your report is accurate.

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