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
Plan Year 2014 MercyCare Medicare Advantage Prior Authorization (PA) Criteria Prior Authorization: MercyCare Medicare Advantage requires you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from MercyCare Medicare Advantage before you fill your prescriptions. If you don’t get approval MercyCare Medicare Advantage
El parto mediante cesárea es cada vez más frecuente. Aunque el útero tiene un mayorriesgo de rotura en una mujer que ha tenido una cesárea, la mayoría de las veces el partovaginal es posible, siendo seguro tanto para la madre como para el feto. Por otro lado, la cesárea electiva rutinaria para el segundo parto de una mujer con unacesárea previa transversa baja genera un exceso de m
Halton Healthcare Services