TRANSFER OF MEDICAL RECORDS 转诊

TRANSFER OF MEDICAL RECORDS (转诊表格)

J-Von Medical Centre (J-Von 医疗中心)
Address: 4468 Beresford Street

Burnaby, BC V5H 2Y8

Tel:778-379-8299

Fax:778-379-8399
Please enter English, please do not enter any Chinese character.

请输入英文，请不要输入中文。
To Dr. 医师名字*
Telephone: 电话*
Fax: 传真*
Patient 1 (病人1)
Name: 名字*
PHN: 医疗卡号*
DOB: 出生日期*
Patient 2 (病人 2)
Name: 名字
PHN: 医疗卡号
DOB: 出生日期
Patient 3 (病人 3)
Name: 名字
PHN: 医疗卡号
DOB: 出生日期
Patient 4 (病人 4)
Name: 名字
PHN: 医疗卡号
DOB: 出生日期
*The above patient(s) are now attending our clinic. As we are a paperless office please forward a summary or a disc of their medical records. OR email to info@jvonmedical.ca. Per, The College of Physicians and

*Surgeons PLEASE DO NOT SEND THE ORIGINAL COPIES.

I understand that this service is not recognized as “medically required” and is not covered by the Medical Services Plan. I realize that there may be a charge for this service and you may bill me accordingly.
Patient 1's Signature 病人1的签名*

Clear
Date 日期*

MonthDayYear
Month-Date-Year 月-日-年
Patient 2's Signature 病人2的签名

Clear
Date 日期

MonthDayYear
Month-Date-Year 月-日-年
Patient 3's Signature 病人3的签名

Clear
Date 日期

MonthDayYear
Month-Date-Year 月-日-年
Patient 4's Signature 病人4的签名

Clear
Date 日期

MonthDayYear
Month-Date-Year 月-日-年
Should be Empty:

TRANSFER OF MEDICAL RECORDS (转诊表格)