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* CONTACT ADDRESS* REFERRING PRACTITIONER NAME* DATE* PROVIDER NUMBER* PHONE* PRACTICE ADDRESS* EMAIL CLINICAL PRESENTATION / POTS SYMPTOMS Postural IntoleranceFainting / Near faintingChest Pain / TightnessNausea / GI DisturbanceCold/Purple ExtremitiesPalpitations / TachycardiaChronic FatigueShortness of BreathExercise IntoleranceSleep DisturbancesDizziness / LightheadednessBrain Fog / Poor ConcentrationHeadache / MigrainesTremulousness / ShakingTemperature Dysregulation ADDITIONAL CLINICAL NOTES Submit Δ
