Nephrology Referral

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

Alternatively, you can refer patients to us through the Ocean Referral System or by downloading and sending 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
Ocean Referral System
70 King St E, Lower Level
Stoney Creek, ON L8G 1K2
Hamilton – Dundas
Ocean Referral System
11 Cross St,
Hamilton, ON L9H 2R3
Hamilton
Ocean Referral System
565 Sanatorium Rd Unit 204,
Hamilton, ON L9C 7N4
Welland
Ocean Referral System
3 Cross St, Unit 301,
Welland, ON L3B 5X6
Cambridge
Ocean Referral System
715 Coronation Blvd, Suite 8,
Cambridge, ON N1R 7R1

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

Central Booking Line

Our Clinic Locations

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