Georgetown / Milton /Oakville Oakville-Trafalgar Memorial Hospital 327 Reynolds Street, Oakville ON L6J 3L7 Ph 905-845-2571 ext 3545 Fax 905-338-4453
Michael Lang, BSc MD FRCPC Anna Labuda, BSc MD FRCPC Physical Medicine & Rehabilitation Physical Medicine & Rehabilitation Requisition for Comprehensive Spasticity Management Clinic
Patient Name: ________________________________________ Birth date: ____________________________ (YYYY / MM / DD) Health Card Number: __________________________________ Gender: ___ M ___ F Address: _____________________________________________________________________________________________ Home Phone: ( )_______________________________ Work Phone: (____)___________________________ Referring Physician: ________________________________ Billing Number: _______________________________ Referring Physician Phone Number: (____)__________________ Fax: (____)__________________________ Referring Physician Address: ____________________________________________________________________________
____________________________________________________________________________ DIAGNOSIS – Please check one Spasticity due to:
Stroke Traumatic Brain Injury Spinal Cord Injury Multiple Sclerosis Cerebral Palsy
Other: ___________________________________________________________________________________________ LIMBS TO BE ASSESSED - Leg: Right Left Arm: Right Left
MEDICAL HISTORY: _________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ CURRENT MEDICATIONS – List attached
Prescription Program Drug list — To be used by members who have a formulary drug plan. Anthem Blue Cross California prescription drug benefits include medications available on the Anthem Drug List. Our prescription drug benefits can offer potential savings when your physician prescribes medications on the drug list. For more information about your drug plan, you can do A. The Anth
THIS IS A NEW SPECIFICATION ADVANCED GCE CHEMISTRY A Monday 28 June 2010 OCR Supplied Materials: Data Sheet for Chemistry A (inserted) Duration: 1 hour Other Materials Required: INSTRUCTIONS TO CANDIDATES Write your name clearly in capital letters, your Centre Number and Candidate Number in the boxes above. Use black ink. Pencil may be used for graphs and diagrams only.
Halton Healthcare Services