/ Clinical Booking Form /

Appointment Date* * Mandatory Field

Start Time* End Time*

Select Telehealth Site Closest to Patient*(sites denoted with © are equipped with a handheld patient exam camera

and ş with the electronic stethoscope)

Other Site:

Consultant* Consultant Specialty*

Consultant Site*

Consultant Phone Fax

Patient Name* DOB* Phone*

Address*

Alternate Contact Relationship SelectParentSpouse /Common LawSiblingSon/DaughterOtherPatientUnknown

Daytime/Alternate Telephone* Conversing Language SelectUnknownEnglishEnglish / CreeEnglish / UkranianCreeUkranianOther

Referring Physician Family Physician

Handicap Access Required

Describe(ie wheelchair, bed, etc)

Talk Only

Assessments Required Prior to Clinic* (check all that apply)

None Vital Signs Weight Height Diabetes Record

Blood Glucose Chest Auscultation Edema Assessment Other

Type of Clinical Support RequiredDuring the clinic*

Assessments Required During Clinic* (check all that apply)

None Vital Signs Weight Height Diabetes Record

Blood Glucose Chest Auscultation Edema Assessment Other (enter below)

Procedures to be CompletedDuring Clinic*(e.g. Memory Clinic support, dressing removal, wound irrigation, etc)

Additional Hand Held Patient Examination CameraRequired?* (only available at patient sites denoted with ©)

Body Area/Part to be Visualized

Electronic Stethoscope Required During Clinic* (only available in patient sites denoted with ş)

Where a fax number is required for the patient site to send ECG or Lab Requsitions, contact the local Telehealth Coordinator.

Additional Information Relevant to this Appointment (ie: specific infectious concerns with the patient)

Sender’s Name* Date*

Sender’s Phone Number* Sender’s E-mail*

When Sending Clinical Booking Form:

  1. Ensure all pertinent information is entered into the form and save a copy to your local computer.
  2. Email form directly to the patient site (see below). In the subject line include the clinic date and the name of the clinical provider (ie Memory Clinic). Send using your standard email processes.

Telehealth Partner / COMMUNITY(s) / PHONE / Clinical E-Mail
Athabasca / Uranium City, Stony Rapids, Fond du Lac and Black Lake / 306-439-2200 ext.278 /
Cypress / Swift Current, Leader, Maple Creek, Shaunavon, Cabri, Gull Lake, Eastend, Ponteix, Mankota and Herbert / 306-778-5444 /
Five Hills / Assiniboia, Moose Jaw, Gravelbourg, Central Butte, Rockglen and Craik / 306-691-2635 /
Heartland / Kindersley, Outlook, Rosetown, Unity, Biggar, Davidson, Eston, Macklin, Kyle, Lucky Lake and Kerrobert / 306-463-6150 ext. 2404 /
Keewatin Yatthe / Beauval, Buffalo Narrows, Ile a la Crosse, La Loche / 306-833-3373 /
Kelsey Trail / Cumberland House, Hudson Bay, Kelvington, Melfort, Nipawin, Tisdale, Porcupine Plain, Carrot River, Arborfield / 306-862-7256 /
Mamawetan Churchill River / Creighton ,La Ronge, Pinehouse, Sandy Bay / 306-425-4819 /
Prairie North / Goodsoil, Lloydminster, Meadow Lake, North Battleford, Battleford, Sask Hospital, Maidstone, Turtleford, Cut Knife / 306-446-6699 /
Prince Albert Parkland / Big River, Prince Albert, Shellbrook, Spiritwood, and Hafford / 306-765-6082 /
Regina Qu’Appelle / Balcarres, Broadview, Grenfell, Moosomin, Wolesely, Indian Head, Lestock and Regina, Fort Qu’Appelle Primary Care Clinic / 306-766-3400 /
Saskatoon / Humboldt, Saskatoon, Rosthern, Watrous, Wadena and Wynyard / 306-655-1007 /
Sun Country / Arcola, Bengough, Cornach, Estevan, Fillmore, Gainsborough, Kipling, Oxbow, Radville, Redvers, Stoughton, Wawota, Weyburn, Carnduff, Lampman, Midale, Maryfield, Pangman and Carlyle / 306-842-8605 /
Sunrise / Kamsack, Melville, Preeceville, Yorkton, Canora, Foam Lake, Langenburg, Esterhazy, Norquay / 306-786-0776 /
Allan Blair Cancer Center / Regina / 306-766-2177 /
Saskatoon Cancer Center / Saskatoon / 306-655-6613 /
File Hills Qu’Appelle Tribal Council / Fort Qu’Appelle ANHH, / 306-332-2657 /
Peter Ballantyne Cree Nation / Southend, Pelican Narrows, Deschambeault Lake, Southend / 306-632-2046 ext 259 /
Agency Chiefs Tribal Council / Big River / 306-717-9093 /
Independents / Onion Lake / 306-344-2330 /
Meadow Lake Tribal Council / Meadow Lake, Flying Dust , Makwa, Island Lake, Canoe Lake, Birch Narrows, Buffalo River, Clearwater River, Mistahey Musqua, Waterhen Lake, English River / 306-236-8233 /
Prince Albert Grand Council / Prince Albert, Hatchet Lake, Cumberland House VL, James Smith, White Buffalo, Red Earth, Sturgeon Lake, Wahpeton, Montreal Lake / 306-953-2783 /
Battle River Treaty 6 / Prince Albert, Little Pine, Moosomin, Mosquito, Poundmaker, Battle River Treaty 6 Health Center, Red Pheasant, Sweet Grass / 306-937-6809 /
Lac La Ronge Indian Band / Lac La Ronge, Little Red River / 306-425-1702 /
First NationsTreatment Centers / Ekweskeet Treatment Center
Leading Thunderbird Lodge
Cree Nations Treatment Haven / 306-344-2094
306-332-5659
306-468-2072 /

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