QSMM Dr. Taher Al-Jishi OBGYN Referral Form 2016-10-31. QSMM Dr. Taher Al-Jishi OBGYN Referral Form 2016-10-31-2026

1. Click ‘Get Form’ to open the QSMM Dr. Taher Al-Jishi OBGYN Referral Form in the editor.
2. Begin by entering the patient's name in the designated field, followed by their date of birth in the format M/D/Y.
3. Fill in the patient's Personal Health Number (PHN) and select their gender by checking either 'M' for male or 'F' for female.
4. Provide the referral source's name and contact details, including telephone and fax numbers.
5. Indicate whether the patient is aware of the referral and include any relevant claims information if applicable.
6. Detail the reason for referral, ensuring to attach any supporting documentation that may assist Dr. Al-Jishi.
7. List any previous history and investigations related to the patient's condition, along with current medications.
8. Select specific services you wish Dr. Al-Jishi to review from the provided options, such as General Gyne Consultation or Prenatal Care.
9. Once completed, save your changes and follow instructions to fax the form to Glenwood Medical Clinic at 587-521-1801.

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