POTS Clinic Referral Form You may fill up the form online below or download PDF and Fax to us. PATIENT INFORMATION NAME* D.O.B (dd/mm/yyyy)* GENDER:* MFX GUARDIAN NAME* RELATIONSHIP TO PATIENT* EMAIL* PHONE* CONTACT ADDRESS* REFERRING PRACTITIONER NAME* DATE* PROVIDER NUMBER* PHONE* PRACTICE ADDRESS* EMAIL CLINICAL PRESENTATION / POTS SYMPTOMS Postural Intolerance Fainting / Near fainting Chest Pain / Tightness Nausea / GI Disturbance Cold/Purple Extremities Palpitations / Tachycardia Chronic Fatigue Shortness of Breath Exercise Intolerance Sleep Disturbances Dizziness / Lightheadedness Brain Fog / Poor Concentration Headache / Migraines Tremulousness / Shaking Temperature Dysregulation ADDITIONAL CLINICAL NOTES Submit Δ
