Nephrology Referral

Use this online form to refer a patient to Dr. Danah Bohemid at Heart and Health Clinic for Nephrology.

Alternatively, please download and send the referral form by email or fax.

Central Booking Line
T: (289) 760-9550
F: (905) 296-3858
E: clinic@heartandhealth.ca

Our Clinic Locations

Hamilton - Stoney Creek
70 King St E, Lower Level
Stoney Creek, ON L8G 1K2

Welland
3 Cross St, Unit 301
Welland, ON L3B 5X6

Patient Name

First Name

Last Name

Health Card Number

Patient Date of Birth

Patient Email

Patient Phone

Select Clinic

Reason for Referral

Chronic Kidney Disease (eGFR < 45ml/min) Electrolyte Disorder (e.g. hyponatremia, hyperkalemia) Proteinuria Hematuria Kidney Stones Resistant or Suspected Secondary Hypertension Acute Kidney Injury (rapid drop in eGFR)

Other

PLEASE ENCLOSE THE FOLLOWING INFORMATION (IF COMPLETED)

List of medications and allergies
List of past medical/surgical history
Serum Creatinine, eGFR values over last 2 years
Urine Studies: Urinalysis, 24-hour urine collection (CrCl, protein), Urine ACR and/or PCR
Renal Ultrasound

Referring Physician Name

Office Address

Contact Phone

Referring Physician's Billing Number (required)

Referring Physician's Fax Number

Referring Physician's Signature

Type your first and last name below to act as your e-signature for the purpose of this referral.

Nephrology Referral

Reason for Referral

PLEASE ENCLOSE THE FOLLOWING INFORMATION (IF COMPLETED)

Heart And Health Clinic Stoney Creek

Heart And Health Clinic Dundas

Heart And Health Clinic Welland

Heart And Health Clinic Cambridge