Bariatrics

This is a draft standardized eReferral form for Bariatrics. Final design may differ.
The form is designed to be viewed on a computer.

For more information about specific sections on the form, please click the yellow "Notes" buttons on the left hand side of the page.

Patient Information

Surname:

First:

DOB:

Gender:

Male

Female

Other

HN:

Mobile #:

Home #:

Business #:

Email:

Address:

* Indicates a required field

[Optional] Additional Patient Information

Sex assigned at birth:

Female

Male

Intersex

Unknown

Pronouns:

He/Him

She/Her

They/Them

Other

Preferred name

Preferred language:

English

French

Other

Best method of contact:

Mobile

Home

Business

Email

Alternate contact

Unsafe contact persons (do not speak with)

Accessibility concerns or disability

Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)

Send copies of reports to additional providers

Exclusion Criteria:

Patients with any of the following are NOT eligible for the Ontario Bariatric Program. Please confirm whether this patient has:

Active drug and/or alcohol addiction*

No

Yes

Active treatment for a major/life-threatening cancer* (e.g. chemotherapy, radiation)

No

Yes

Significant psychiatric illness that is inadequately treated*

No

Yes

Note: Smoking is not an exclusion criteria, however, patients are encouraged to abstain from smoking for at least 6 months prior to start of medical or surgical program, with continued abstinence if surgery is to be considered.

Eligibility Criteria

Age

Patient >18 years old*

Insurance

Patient has an Ontario Health Card OR is a resident of Ontario and meets one of the following: *

• A member of the Canadian Armed Forces (CAF) and has health coverage under the Military Health Care Plan

• A member of the Royal Canadian Mounted Police (RCMP) and has health coverage under the Federal Public

Service Health Care Plan

• Status Indian and has health coverage under Health Canada’s First Nation and Inuit Health Program

• A refugee and has health coverage under the Interim Federal Health Program (IFHP)

• Has other health coverage through another program not listed above.

Body Mass Index

Height (cm):

Weight (kgs):

BMI:

Switch to imperial units (ft and lbs)

Previous Bariatric Surgery

Select if applicable:

Previously had bariatric surgery

Comorbid conditions:

Select all that apply:

Idiopathic intracranial hypertension

Coronary heart disease

Type 2 diabetes

Hypertension

Diagnosed sleep apnea

Gastroesophageal reflux disease (GERD)

Renal disease

Additional Relevant Information (if applicable):

Eligible Services *

Please enter height, weight and indicate applicable eligibility factors above.

From the information entered, your patient is NOT currently eligible for any of the OBN programs.

Medical Program:

• BMI ≥35; OR

• BMI ≥30 and at least 1 of the following comorbidities:

o Complicated Type 2 diabetes mellitus

o Idiopathic intracranial hypertension

o Poorly controlled hypertension

Surgical Program:

• BMI ≥40 OR

• BMI ≥35 and at least 1 of the following comorbidities:

o Coronary heart disease

o Type 2 Diabetes mellitus

o Hypertension

o Diagnosed sleep apnea

o Gastroesophageal Reflux Disease (GERD)

Pilot Metabolic Program:

• BMI 28 to 35 with complicated Type 2 Diabetes

See the following link for more details:

OBN Programs and Eligibility

Helper

Cumulative Patient Profile

Please delete any sensitive information you do not intend to share from the CPP

CPP attached separately (if not entered below)

Current Problem List:

Past Medical History:

Current Medications:

Family History:

Allergies:

Supporting Documentation

Please attach all relevant:

Consult reports or discharge summaries
Laboratory and diagnostic investigations
Assessments or patient-reported scales (e.g. PHQ-9, GAD-7)

Personal Health Information that is medically relevant has not been disclosed at the request of the patient.

+ Add Attachments

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Referrer's Information

Site Name:

Address:

City:

Province:

Postal Code:

Phone:

Fax:

Billing #:

Professional ID:

Signed:

Role:

Thank you for taking time to review this form.
Ontario Health & Amplify Care

Notes

Overview

This referral form is intended for consultations in community settings
Formatting and style is intended to be consistent across all specialties to reduce cognitive loads
The number of mandatory fields is limited to reduce administrative burdens.

X

Notes

Patient Information

These fields are auto-populated when referral is initiated from an integrated Electronic Medical Record (EMR) or Hospital Information System (HIS).

X

Notes

Additional Patient Information

This section is optional for referrers to complete
Referring providers should use their judgement to determine if any of these fields should be completed. Some fields will auto-complete if launched from an integrated EMR or HIS.

X

Notes

Cumulative Patient Profile (CPP)

This section auto-populates when referral is initiated from an integrated Eletronic Medical Record (EMR) or Hospital Information System (HIS)
Selecting “CPP attached separately” will hide this section.

X

Notes

Referrer’s Information

Will automatically populate with the referring provider’s information.

X

OK

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