<CodeSystem xmlns="http://hl7.org/fhir">
  <id value="example-referral-form-codes" />
  <text>
    <status value="generated" />
    <div xmlns="http://www.w3.org/1999/xhtml">
      <p class="res-header-id">
        <b>Generated Narrative: CodeSystem example-referral-form-codes</b>
      </p>
      <a name="example-referral-form-codes"></a>
      <a name="hcexample-referral-form-codes"></a>
      <p>This case-sensitive code system <code>http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes</code> defines the following codes:</p>
      <table class="codes">
        <tr>
          <td style="white-space:nowrap">
            <b>Code</b>
          </td>
          <td>
            <b>Display</b>
          </td>
          <td>
            <b>French (fr)</b>
          </td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20001<a name="example-referral-form-codes-20001"></a></td>
          <td>Cardiac Testing</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20002<a name="example-referral-form-codes-20002"></a></td>
          <td>Cardiology Consultation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20003<a name="example-referral-form-codes-20003"></a></td>
          <td>24 Hour Ambulatory Blood Pressure Monitoring (Not OHIP Covered)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20004<a name="example-referral-form-codes-20004"></a></td>
          <td>Coronary Angiogram</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20005<a name="example-referral-form-codes-20005"></a></td>
          <td>Echocardiogram - Resting</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20006<a name="example-referral-form-codes-20006"></a></td>
          <td>Electrocardiogram (ECG)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20007<a name="example-referral-form-codes-20007"></a></td>
          <td>Holter Monitoring</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20008<a name="example-referral-form-codes-20008"></a></td>
          <td>Loop / Event Monitor</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20009<a name="example-referral-form-codes-20009"></a></td>
          <td>Stress Testing</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20010<a name="example-referral-form-codes-20010"></a></td>
          <td>Nuclear Medicine</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20011<a name="example-referral-form-codes-20011"></a></td>
          <td>Tilt Table Testing</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20012<a name="example-referral-form-codes-20012"></a></td>
          <td>Echocardiogram (2D)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20013<a name="example-referral-form-codes-20013"></a></td>
          <td>Echocardiogram with Contrast</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20014<a name="example-referral-form-codes-20014"></a></td>
          <td>Echocardiogram with Saline (Bubble)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20015<a name="example-referral-form-codes-20015"></a></td>
          <td>Pediatric Echocardiogram</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20016<a name="example-referral-form-codes-20016"></a></td>
          <td>Transesophageal Echocardiogram (TEE)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20017<a name="example-referral-form-codes-20017"></a></td>
          <td>24 Hours</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20018<a name="example-referral-form-codes-20018"></a></td>
          <td>48 Hours</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20019<a name="example-referral-form-codes-20019"></a></td>
          <td>72 Hours</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20020<a name="example-referral-form-codes-20020"></a></td>
          <td>7 Days</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20021<a name="example-referral-form-codes-20021"></a></td>
          <td>14 Days</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20022<a name="example-referral-form-codes-20022"></a></td>
          <td>ECG - Exercise Stress Test</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20023<a name="example-referral-form-codes-20023"></a></td>
          <td>ECG - Dobutamine/Persantine Stress Test</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20024<a name="example-referral-form-codes-20024"></a></td>
          <td>Echocardiogram - Exercise Stress Test</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20025<a name="example-referral-form-codes-20025"></a></td>
          <td>Echocardiogram - Dobutamine/Persantine Stress Test</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20026<a name="example-referral-form-codes-20026"></a></td>
          <td>MUGA - Resting</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20027<a name="example-referral-form-codes-20027"></a></td>
          <td>Cardiac Pyrophosphate</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20028<a name="example-referral-form-codes-20028"></a></td>
          <td>MIBI Scans / Myocardial Perfusion Imaging (MPI):</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20029<a name="example-referral-form-codes-20029"></a></td>
          <td>MIBI Scan - Exercise Stress Test</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20030<a name="example-referral-form-codes-20030"></a></td>
          <td>MIBI Scan - Dobutamine/Persantine Stress Test</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20031<a name="example-referral-form-codes-20031"></a></td>
          <td>Thallium Viability Test</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20032<a name="example-referral-form-codes-20032"></a></td>
          <td>Arrythmias or Palpitations</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20033<a name="example-referral-form-codes-20033"></a></td>
          <td>Cardiovascular Risk Assessment</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20034<a name="example-referral-form-codes-20034"></a></td>
          <td>Chest Pain or Angina</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20035<a name="example-referral-form-codes-20035"></a></td>
          <td>Congenital Heart Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20036<a name="example-referral-form-codes-20036"></a></td>
          <td>Congestive Heart Failure</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20037<a name="example-referral-form-codes-20037"></a></td>
          <td>Coronary Artery Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20038<a name="example-referral-form-codes-20038"></a></td>
          <td>Dyspnea</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20039<a name="example-referral-form-codes-20039"></a></td>
          <td>Hypertension</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20040<a name="example-referral-form-codes-20040"></a></td>
          <td>Murmur</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20041<a name="example-referral-form-codes-20041"></a></td>
          <td>Pericardial Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20042<a name="example-referral-form-codes-20042"></a></td>
          <td>Peripheral Edema</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20043<a name="example-referral-form-codes-20043"></a></td>
          <td>Post-Myocardial Infarction</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20044<a name="example-referral-form-codes-20044"></a></td>
          <td>Pre-Operative Consultation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20045<a name="example-referral-form-codes-20045"></a></td>
          <td>Syncope</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20046<a name="example-referral-form-codes-20046"></a></td>
          <td>Valvular Heart Disease or Prosthetic Heart Valve</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20047<a name="example-referral-form-codes-20047"></a></td>
          <td>Acne or Rosacea</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20048<a name="example-referral-form-codes-20048"></a></td>
          <td>Alopecia or Hair Loss</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20049<a name="example-referral-form-codes-20049"></a></td>
          <td>Cosmetic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20050<a name="example-referral-form-codes-20050"></a></td>
          <td>Eczema or Dermatitis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20051<a name="example-referral-form-codes-20051"></a></td>
          <td>Hidradenitis Suppurativa</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20052<a name="example-referral-form-codes-20052"></a></td>
          <td>Hives or Urticaria</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20053<a name="example-referral-form-codes-20053"></a></td>
          <td>Nail Concerns</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20054<a name="example-referral-form-codes-20054"></a></td>
          <td>Pruritus NYD</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20055<a name="example-referral-form-codes-20055"></a></td>
          <td>Psoriasis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20056<a name="example-referral-form-codes-20056"></a></td>
          <td>Rash NYD</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20057<a name="example-referral-form-codes-20057"></a></td>
          <td>Skin Cancer or Suspicious Lesion(s)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20058<a name="example-referral-form-codes-20058"></a></td>
          <td>Skin Check</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20059<a name="example-referral-form-codes-20059"></a></td>
          <td>Skin Infection - Chronic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20060<a name="example-referral-form-codes-20060"></a></td>
          <td>Ulcer or Wounds</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20061<a name="example-referral-form-codes-20061"></a></td>
          <td>Warts</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20062<a name="example-referral-form-codes-20062"></a></td>
          <td>Vitiligo</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20063<a name="example-referral-form-codes-20063"></a></td>
          <td>Actinic Keratoses</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20064<a name="example-referral-form-codes-20064"></a></td>
          <td>Basal Cell Cancer</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20065<a name="example-referral-form-codes-20065"></a></td>
          <td>Squamous Cell Cancer</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20066<a name="example-referral-form-codes-20066"></a></td>
          <td>Melanoma</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20067<a name="example-referral-form-codes-20067"></a></td>
          <td>Suspicious Lesion(s)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20068<a name="example-referral-form-codes-20068"></a></td>
          <td>Biopsy confirmed</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20069<a name="example-referral-form-codes-20069"></a></td>
          <td>Abdominal Pain NYD or Bloating</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20070<a name="example-referral-form-codes-20070"></a></td>
          <td>Barrett's Esophagus - Surveillance</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20071<a name="example-referral-form-codes-20071"></a></td>
          <td>Bleeding</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20072<a name="example-referral-form-codes-20072"></a></td>
          <td>Colonoscopy Request (Abnormal FIT, Screening, Surveillance)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20073<a name="example-referral-form-codes-20073"></a></td>
          <td>Bowel Changes (Constipation, Diarrhea)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20074<a name="example-referral-form-codes-20074"></a></td>
          <td>Dysphagia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20075<a name="example-referral-form-codes-20075"></a></td>
          <td>Gastroesophageal Reflux Disease (GERD)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20076<a name="example-referral-form-codes-20076"></a></td>
          <td>Irritable Bowel Syndrome</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20077<a name="example-referral-form-codes-20077"></a></td>
          <td>Inflammatory Bowel Disease (IBD)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20078<a name="example-referral-form-codes-20078"></a></td>
          <td>Iron Deficiency Anemia - Unexplained</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20079<a name="example-referral-form-codes-20079"></a></td>
          <td>Liver Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20080<a name="example-referral-form-codes-20080"></a></td>
          <td>Nausea or Vomiting NYD</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20081<a name="example-referral-form-codes-20081"></a></td>
          <td>Pancreatic Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20082<a name="example-referral-form-codes-20082"></a></td>
          <td>Weight Loss - Unexplained</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20083<a name="example-referral-form-codes-20083"></a></td>
          <td>Lower GI or Rectal</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20084<a name="example-referral-form-codes-20084"></a></td>
          <td>Upper GI</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20085<a name="example-referral-form-codes-20085"></a></td>
          <td>Constipation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20086<a name="example-referral-form-codes-20086"></a></td>
          <td>Diarrhea</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20087<a name="example-referral-form-codes-20087"></a></td>
          <td>Abnormal FIT</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20088<a name="example-referral-form-codes-20088"></a></td>
          <td>Average Risk</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20089<a name="example-referral-form-codes-20089"></a></td>
          <td>First-Degree Relative with Colorectal Cancer</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20090<a name="example-referral-form-codes-20090"></a></td>
          <td>Other Family History</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20091<a name="example-referral-form-codes-20091"></a></td>
          <td>Prior History of Colorectal Polyps</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20092<a name="example-referral-form-codes-20092"></a></td>
          <td>Prior History of Colorectal Cancer</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20093<a name="example-referral-form-codes-20093"></a></td>
          <td>Surveillance in IBD Colitis of at least 8 years duration</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20094<a name="example-referral-form-codes-20094"></a></td>
          <td>Crohn's disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20095<a name="example-referral-form-codes-20095"></a></td>
          <td>Ulcerative colitis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20096<a name="example-referral-form-codes-20096"></a></td>
          <td>Alcohol Associated Liver Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20097<a name="example-referral-form-codes-20097"></a></td>
          <td>Cirrhosis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20098<a name="example-referral-form-codes-20098"></a></td>
          <td>Hepatitis B</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20099<a name="example-referral-form-codes-20099"></a></td>
          <td>Hepatitis C</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20100<a name="example-referral-form-codes-20100"></a></td>
          <td>Liver Function Tests - Abnormal</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20101<a name="example-referral-form-codes-20101"></a></td>
          <td>Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) / Fatty Liver</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20102<a name="example-referral-form-codes-20102"></a></td>
          <td>Abnormal Imaging of Pancreas</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20103<a name="example-referral-form-codes-20103"></a></td>
          <td>Pancreatitis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20104<a name="example-referral-form-codes-20104"></a></td>
          <td>Ear and Hearing</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20105<a name="example-referral-form-codes-20105"></a></td>
          <td>Facial Plastics &amp; Reconstruction</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20106<a name="example-referral-form-codes-20106"></a></td>
          <td>Head, Neck and Thyroid (Malignancy, Masses, Nodules, or Cysts)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20107<a name="example-referral-form-codes-20107"></a></td>
          <td>Nose and Sinus</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20108<a name="example-referral-form-codes-20108"></a></td>
          <td>Throat and Oral Cavity</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20109<a name="example-referral-form-codes-20109"></a></td>
          <td>Cerumen Impaction</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20110<a name="example-referral-form-codes-20110"></a></td>
          <td>Eustachian Tube Dysfunction</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20111<a name="example-referral-form-codes-20111"></a></td>
          <td>Hearing Loss - Sudden / Unilateral</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20112<a name="example-referral-form-codes-20112"></a></td>
          <td>Otitis Externa</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20113<a name="example-referral-form-codes-20113"></a></td>
          <td>Otitis Media</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20114<a name="example-referral-form-codes-20114"></a></td>
          <td>Tinnitus</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20115<a name="example-referral-form-codes-20115"></a></td>
          <td>Vertigo or Dizziness</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20116<a name="example-referral-form-codes-20116"></a></td>
          <td>Nasopharyngeal Lesions</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20117<a name="example-referral-form-codes-20117"></a></td>
          <td>Oropharyngeal Lesions</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20118<a name="example-referral-form-codes-20118"></a></td>
          <td>Parathyroid Cyst, Nodule, or Mass</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20119<a name="example-referral-form-codes-20119"></a></td>
          <td>Salivary Gland Mass</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20120<a name="example-referral-form-codes-20120"></a></td>
          <td>Skin Cancer</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20121<a name="example-referral-form-codes-20121"></a></td>
          <td>Thyroid Cyst, Nodule, or Mass</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20122<a name="example-referral-form-codes-20122"></a></td>
          <td>Anosmia or Hyposmia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20123<a name="example-referral-form-codes-20123"></a></td>
          <td>Deviated Nasal Septum</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20124<a name="example-referral-form-codes-20124"></a></td>
          <td>Epistaxis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20125<a name="example-referral-form-codes-20125"></a></td>
          <td>Foreign Body Removal</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20126<a name="example-referral-form-codes-20126"></a></td>
          <td>Nasal Polyps</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20127<a name="example-referral-form-codes-20127"></a></td>
          <td>Rhinitis or Sinusitis - Chronic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20128<a name="example-referral-form-codes-20128"></a></td>
          <td>Cough or Throat Clearing - Chronic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20130<a name="example-referral-form-codes-20130"></a></td>
          <td>Dysphonia / Hoarse voice</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20131<a name="example-referral-form-codes-20131"></a></td>
          <td>Globus Sensation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20132<a name="example-referral-form-codes-20132"></a></td>
          <td>Lymphadenopathy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20133<a name="example-referral-form-codes-20133"></a></td>
          <td>Odynophagia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20134<a name="example-referral-form-codes-20134"></a></td>
          <td>Salivary Gland Stones</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20135<a name="example-referral-form-codes-20135"></a></td>
          <td>Sleep-Related Breathing Disorders (e.g. OSA)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20136<a name="example-referral-form-codes-20136"></a></td>
          <td>Speech and Language Delay</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20137<a name="example-referral-form-codes-20137"></a></td>
          <td>Tongue Tie</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20138<a name="example-referral-form-codes-20138"></a></td>
          <td>Tonsillar or Adenoid Disorders</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20139<a name="example-referral-form-codes-20139"></a></td>
          <td>Respiratory Testing</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20140<a name="example-referral-form-codes-20140"></a></td>
          <td>Respirology Consultation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20141<a name="example-referral-form-codes-20141"></a></td>
          <td>Spirometry (Include post-bronchodilator, if indicated)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20142<a name="example-referral-form-codes-20142"></a></td>
          <td>Full Pulmonary Function Testing (Include post-bronchodilator, if indicated)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20143<a name="example-referral-form-codes-20143"></a></td>
          <td>Asthma</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20144<a name="example-referral-form-codes-20144"></a></td>
          <td>Cough NYD</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20145<a name="example-referral-form-codes-20145"></a></td>
          <td>Chronic Obstructive Pulmonary Disease (COPD)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20146<a name="example-referral-form-codes-20146"></a></td>
          <td>Dyspnea NYD</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20147<a name="example-referral-form-codes-20147"></a></td>
          <td>Interstitial Lung Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20148<a name="example-referral-form-codes-20148"></a></td>
          <td>Adrenal Mass</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20149<a name="example-referral-form-codes-20149"></a></td>
          <td>Benign Prostatic Hyperplasia (BPH) / Lower Urinary Tract Symptoms (LUTS)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20150<a name="example-referral-form-codes-20150"></a></td>
          <td>Bladder Mass</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20151<a name="example-referral-form-codes-20151"></a></td>
          <td>Elevated Prostate-Specific Antigen (PSA) or Suspicious Digital Rectal Exam (DRE)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20152<a name="example-referral-form-codes-20152"></a></td>
          <td>Erectile Dysfunction</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20153<a name="example-referral-form-codes-20153"></a></td>
          <td>Hematuria</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20154<a name="example-referral-form-codes-20154"></a></td>
          <td>Hydrocele, Varicocele or Spermatocele</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20155<a name="example-referral-form-codes-20155"></a></td>
          <td>Hydronephrosis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20156<a name="example-referral-form-codes-20156"></a></td>
          <td>Hypogonadism</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20157<a name="example-referral-form-codes-20157"></a></td>
          <td>Infertility - Male</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20158<a name="example-referral-form-codes-20158"></a></td>
          <td>Penile Lesion</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20159<a name="example-referral-form-codes-20159"></a></td>
          <td>Peyronie's Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20160<a name="example-referral-form-codes-20160"></a></td>
          <td>Phimosis, Foreskin Issue or Balanitis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20161<a name="example-referral-form-codes-20161"></a></td>
          <td>Renal Mass or Cyst</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20162<a name="example-referral-form-codes-20162"></a></td>
          <td>Nephrolithiasis / Renal Colic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20163<a name="example-referral-form-codes-20163"></a></td>
          <td>Testicular Mass</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20164<a name="example-referral-form-codes-20164"></a></td>
          <td>Urinary Incontinence or Overactive Bladder</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20165<a name="example-referral-form-codes-20165"></a></td>
          <td>Urinary Tract Infections - Recurrent</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20166<a name="example-referral-form-codes-20166"></a></td>
          <td>Vasectomy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20167<a name="example-referral-form-codes-20167"></a></td>
          <td>Gross</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20168<a name="example-referral-form-codes-20168"></a></td>
          <td>Microscopic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20169<a name="example-referral-form-codes-20169"></a></td>
          <td>Imaging demonstrates an obstructive stone</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20170<a name="example-referral-form-codes-20170"></a></td>
          <td>Neurodiagnostic Testing - Triage to Consult if Appropriate</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20171<a name="example-referral-form-codes-20171"></a></td>
          <td>Neurodiagnostic Testing Only (EEG, EMG/NCS)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20172<a name="example-referral-form-codes-20172"></a></td>
          <td>Neurology Consultation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20173<a name="example-referral-form-codes-20173"></a></td>
          <td>Electroencephalography (EEG)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20174<a name="example-referral-form-codes-20174"></a></td>
          <td>Electromyography (EMG) / Nerve Conduction Study (NCS)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20175<a name="example-referral-form-codes-20175"></a></td>
          <td>Routine EEG</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20176<a name="example-referral-form-codes-20176"></a></td>
          <td>Sleep Deprived EEG</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20177<a name="example-referral-form-codes-20177"></a></td>
          <td>Carpal Tunnel Syndrome</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20178<a name="example-referral-form-codes-20178"></a></td>
          <td>Cervical Radiculopathy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20179<a name="example-referral-form-codes-20179"></a></td>
          <td>Lumbar Radiculopathy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20180<a name="example-referral-form-codes-20180"></a></td>
          <td>Peripheral Neuropathy / Polyneuropathy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20181<a name="example-referral-form-codes-20181"></a></td>
          <td>Balance, Dizziness, or Vertigo</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20182<a name="example-referral-form-codes-20182"></a></td>
          <td>Concussion or Traumatic Brain Injury (TBI)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20183<a name="example-referral-form-codes-20183"></a></td>
          <td>Epilepsy or Seizure</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20184<a name="example-referral-form-codes-20184"></a></td>
          <td>Headache or Migraines</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20185<a name="example-referral-form-codes-20185"></a></td>
          <td>Movement Disorders (including Parkinson's and Tremors)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20186<a name="example-referral-form-codes-20186"></a></td>
          <td>Multiple Sclerosis or Demyelinating Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20187<a name="example-referral-form-codes-20187"></a></td>
          <td>Neurocognitive Disorder</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20188<a name="example-referral-form-codes-20188"></a></td>
          <td>Neuropathy or Weakness</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20190<a name="example-referral-form-codes-20190"></a></td>
          <td>Stroke or TIA</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20191<a name="example-referral-form-codes-20191"></a></td>
          <td>Crystal Arthropathies (Gout, Pseudogout)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20192<a name="example-referral-form-codes-20192"></a></td>
          <td>Connective Tissue Diseases (Lupus, Sjogren's, Scleroderma, Inflammatory Myositis)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20193<a name="example-referral-form-codes-20193"></a></td>
          <td>Corticosteroid Injections (Osteoarthritis / Tendinitis / Bursitis / Joint Injections)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20194<a name="example-referral-form-codes-20194"></a></td>
          <td>Giant Cell Arteritis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20195<a name="example-referral-form-codes-20195"></a></td>
          <td>Inflammatory Arthritis (e.g. Rheumatoid Arthritis)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20196<a name="example-referral-form-codes-20196"></a></td>
          <td>Polymyalgia Rheumatica</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20197<a name="example-referral-form-codes-20197"></a></td>
          <td>Psoriatic Arthritis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20198<a name="example-referral-form-codes-20198"></a></td>
          <td>Spondyloarthritis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20199<a name="example-referral-form-codes-20199"></a></td>
          <td>Vasculitis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20200<a name="example-referral-form-codes-20200"></a></td>
          <td>= 3 attacks in the last year</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20201<a name="example-referral-form-codes-20201"></a></td>
          <td>Alopecia / sicca / oral ulcers</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20202<a name="example-referral-form-codes-20202"></a></td>
          <td>Arterial / venous thrombosis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20203<a name="example-referral-form-codes-20203"></a></td>
          <td>Glomerulonephritis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20204<a name="example-referral-form-codes-20204"></a></td>
          <td>Hemolytic anemia / ITP</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20205<a name="example-referral-form-codes-20205"></a></td>
          <td>Inflammatory Arthritis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20207<a name="example-referral-form-codes-20207"></a></td>
          <td>Objective proximal muscle weakness and high CK</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20208<a name="example-referral-form-codes-20208"></a></td>
          <td>Pericarditis / pleural effusions</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20209<a name="example-referral-form-codes-20209"></a></td>
          <td>Photosensitivity and rash</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20210<a name="example-referral-form-codes-20210"></a></td>
          <td>Pregnancy loss (recurrent)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20211<a name="example-referral-form-codes-20211"></a></td>
          <td>Raynaud�s phenomenon</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20212<a name="example-referral-form-codes-20212"></a></td>
          <td>Sclerodactyly / puffy fingers</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20213<a name="example-referral-form-codes-20213"></a></td>
          <td>Referred for temporal artery biopsy or ultrasound</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20214<a name="example-referral-form-codes-20214"></a></td>
          <td>Vision loss or diplopia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20215<a name="example-referral-form-codes-20215"></a></td>
          <td>New headache</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20216<a name="example-referral-form-codes-20216"></a></td>
          <td>Jaw claudication</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20217<a name="example-referral-form-codes-20217"></a></td>
          <td>Scalp tenderness</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20218<a name="example-referral-form-codes-20218"></a></td>
          <td>Significant weight loss or malaise</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20219<a name="example-referral-form-codes-20219"></a></td>
          <td>Unexplained dry cough</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20220<a name="example-referral-form-codes-20220"></a></td>
          <td>Ankylosing Spondylitis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20221<a name="example-referral-form-codes-20221"></a></td>
          <td>Reactive Arthritis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20222<a name="example-referral-form-codes-20222"></a></td>
          <td>IBD Related Arthritis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20223<a name="example-referral-form-codes-20223"></a></td>
          <td>Contraception</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20224<a name="example-referral-form-codes-20224"></a></td>
          <td>Fertility and Infertility</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20225<a name="example-referral-form-codes-20225"></a></td>
          <td>Gynecology</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20226<a name="example-referral-form-codes-20226"></a></td>
          <td>Obstetrics (Routine)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20227<a name="example-referral-form-codes-20227"></a></td>
          <td>Obstetrics (High Risk)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20228<a name="example-referral-form-codes-20228"></a></td>
          <td>Pregnancy Termination</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20229<a name="example-referral-form-codes-20229"></a></td>
          <td>Transgender Care</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20230<a name="example-referral-form-codes-20230"></a></td>
          <td>Contraceptive Counselling</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20231<a name="example-referral-form-codes-20231"></a></td>
          <td>IUD Insertion</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20232<a name="example-referral-form-codes-20232"></a></td>
          <td>IUD Removal</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20233<a name="example-referral-form-codes-20233"></a></td>
          <td>Contraceptive Implant Insertion</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20234<a name="example-referral-form-codes-20234"></a></td>
          <td>Contraceptive Implant Removal</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20235<a name="example-referral-form-codes-20235"></a></td>
          <td>Fertility Status Evaluation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20236<a name="example-referral-form-codes-20236"></a></td>
          <td>Recurrent Pregnancy Loss</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20237<a name="example-referral-form-codes-20237"></a></td>
          <td>Abnormal Cervical Cancer Screening</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20238<a name="example-referral-form-codes-20238"></a></td>
          <td>Abnormal Uterine Bleeding</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20239<a name="example-referral-form-codes-20239"></a></td>
          <td>Adnexal Mass or Cyst</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20240<a name="example-referral-form-codes-20240"></a></td>
          <td>Amenorrhea</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20241<a name="example-referral-form-codes-20241"></a></td>
          <td>Dyspareunia or Vaginismus</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20242<a name="example-referral-form-codes-20242"></a></td>
          <td>Early Pregnancy Loss or Complication</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20243<a name="example-referral-form-codes-20243"></a></td>
          <td>Endometriosis or Pelvic Pain</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20244<a name="example-referral-form-codes-20244"></a></td>
          <td>Menopause Management (including Hormone Replacement Therapy)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20245<a name="example-referral-form-codes-20245"></a></td>
          <td>Pelvic Inflammatory Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20246<a name="example-referral-form-codes-20246"></a></td>
          <td>Polycystic Ovarian Syndrome (PCOS)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20247<a name="example-referral-form-codes-20247"></a></td>
          <td>Post-Menopausal Bleeding</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20248<a name="example-referral-form-codes-20248"></a></td>
          <td>Pelvic Organ Prolapse or Pessary Management</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20249<a name="example-referral-form-codes-20249"></a></td>
          <td>Urinary Incontinence</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20250<a name="example-referral-form-codes-20250"></a></td>
          <td>Uterine Fibroids, Polyps, Septum, or Other Structural Abnormalities</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20251<a name="example-referral-form-codes-20251"></a></td>
          <td>Vaginitis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20252<a name="example-referral-form-codes-20252"></a></td>
          <td>Vulvar, Vaginal, or Cervical Disorders</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20253<a name="example-referral-form-codes-20253"></a></td>
          <td>Total Antenatal Care</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20254<a name="example-referral-form-codes-20254"></a></td>
          <td>Shared Antenatal Care</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20255<a name="example-referral-form-codes-20255"></a></td>
          <td>Obstetrical Consult</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20256<a name="example-referral-form-codes-20256"></a></td>
          <td>Last Menstrual Period (LMP)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20257<a name="example-referral-form-codes-20257"></a></td>
          <td>Estimated Date of Delivery (EDD)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20258<a name="example-referral-form-codes-20258"></a></td>
          <td>GTPAL</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20259<a name="example-referral-form-codes-20259"></a></td>
          <td>Abnormal Prenatal Screen</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20260<a name="example-referral-form-codes-20260"></a></td>
          <td>Congenital Abnormalities</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20261<a name="example-referral-form-codes-20261"></a></td>
          <td>Diabetes (pre-existing)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20262<a name="example-referral-form-codes-20262"></a></td>
          <td>Gestational Diabetes</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20263<a name="example-referral-form-codes-20263"></a></td>
          <td>HIV Pregnancy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20265<a name="example-referral-form-codes-20265"></a></td>
          <td>Infectious Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20266<a name="example-referral-form-codes-20266"></a></td>
          <td>Intrauterine Growth Restriction</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20267<a name="example-referral-form-codes-20267"></a></td>
          <td>Medical Disease in Pregnancy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20268<a name="example-referral-form-codes-20268"></a></td>
          <td>Multiple Gestation (Twins, Triplets, Higher Order)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20269<a name="example-referral-form-codes-20269"></a></td>
          <td>Placental Abnormalities</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20270<a name="example-referral-form-codes-20270"></a></td>
          <td>Pre-Conception Counselling</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20271<a name="example-referral-form-codes-20271"></a></td>
          <td>Substance Abuse in Pregnancy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20272<a name="example-referral-form-codes-20272"></a></td>
          <td>Current gestational age</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20273<a name="example-referral-form-codes-20273"></a></td>
          <td>Bicytopenia or Pancytopenia (decreases in more than one cell line)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20274<a name="example-referral-form-codes-20274"></a></td>
          <td>Bleeding or Abnormal INR/PTT</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20275<a name="example-referral-form-codes-20275"></a></td>
          <td>Confirmed Malignant Hematology Consultation (biopsy proven)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20276<a name="example-referral-form-codes-20276"></a></td>
          <td>Red Blood Cells or Iron</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20277<a name="example-referral-form-codes-20277"></a></td>
          <td>Myeloma or Paraproteinemia (e.g. Bence Jones proteinuria, monoclonal gammopathy)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20278<a name="example-referral-form-codes-20278"></a></td>
          <td>Lymph Nodes or Spleen</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20279<a name="example-referral-form-codes-20279"></a></td>
          <td>Platelets</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20280<a name="example-referral-form-codes-20280"></a></td>
          <td>Thrombosis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20281<a name="example-referral-form-codes-20281"></a></td>
          <td>Transfusion</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20282<a name="example-referral-form-codes-20282"></a></td>
          <td>White Blood Cells</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20283<a name="example-referral-form-codes-20283"></a></td>
          <td>Other Benign Hematology Consultation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20284<a name="example-referral-form-codes-20284"></a></td>
          <td>Other Malignant Hematology Consultation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20285<a name="example-referral-form-codes-20285"></a></td>
          <td>Labs abnormal - no bleeding / bruising</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20286<a name="example-referral-form-codes-20286"></a></td>
          <td>Abnormal bleeding / bruising</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20287<a name="example-referral-form-codes-20287"></a></td>
          <td>Anemia NYD</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20288<a name="example-referral-form-codes-20288"></a></td>
          <td>Anemia - Iron Deficiency</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20289<a name="example-referral-form-codes-20289"></a></td>
          <td>Erythrocytosis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20290<a name="example-referral-form-codes-20290"></a></td>
          <td>Ferritin - High</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20291<a name="example-referral-form-codes-20291"></a></td>
          <td>Hemoglobinopathy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20292<a name="example-referral-form-codes-20292"></a></td>
          <td>Sickle Cell Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20293<a name="example-referral-form-codes-20293"></a></td>
          <td>Thallasemias</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20294<a name="example-referral-form-codes-20294"></a></td>
          <td>Other Hemoglobinopathy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20295<a name="example-referral-form-codes-20295"></a></td>
          <td>Lymphadenopathy - Concern for Lymphoma</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20296<a name="example-referral-form-codes-20296"></a></td>
          <td>Lymphoma</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20297<a name="example-referral-form-codes-20297"></a></td>
          <td>Splenomegaly</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20298<a name="example-referral-form-codes-20298"></a></td>
          <td>Thrombocytopenia (low platelets)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20299<a name="example-referral-form-codes-20299"></a></td>
          <td>Thrombocytosis (high platelets)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20300<a name="example-referral-form-codes-20300"></a></td>
          <td>Atrial Fibrillation Anticoagulation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20301<a name="example-referral-form-codes-20301"></a></td>
          <td>Mechanical Valve Anticoagulation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20302<a name="example-referral-form-codes-20302"></a></td>
          <td>Peripartum Thrombosis - Prevention or Treatment</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20303<a name="example-referral-form-codes-20303"></a></td>
          <td>Peri-procedure Anticoagulation Management</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20304<a name="example-referral-form-codes-20304"></a></td>
          <td>Superficial Vein Thrombosis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20305<a name="example-referral-form-codes-20305"></a></td>
          <td>Thrombophilia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20306<a name="example-referral-form-codes-20306"></a></td>
          <td>Venous Thromboembolism - Acute - Imaging Confirmed (e.g. DVT, PE)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20307<a name="example-referral-form-codes-20307"></a></td>
          <td>Venous Thromboembolism - Chronic (e.g. DVT, PE)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20308<a name="example-referral-form-codes-20308"></a></td>
          <td>Other Thrombosis Consultation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20309<a name="example-referral-form-codes-20309"></a></td>
          <td>Acute Leukemia (myeloid or lymphoblastic)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20310<a name="example-referral-form-codes-20310"></a></td>
          <td>Chronic Leukemia (myeloid or lymphoblastic)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20311<a name="example-referral-form-codes-20311"></a></td>
          <td>Leukocytosis (high white blood cells)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20312<a name="example-referral-form-codes-20312"></a></td>
          <td>Leukopenia (low white blood cells, including low neutrophil count)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20313<a name="example-referral-form-codes-20313"></a></td>
          <td>Acute Kidney Injury (AKI)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20314<a name="example-referral-form-codes-20314"></a></td>
          <td>Chronic Kidney Disease (CKD)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20315<a name="example-referral-form-codes-20315"></a></td>
          <td>Electrolyte Disorders</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20318<a name="example-referral-form-codes-20318"></a></td>
          <td>Imaging Abnormalities</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20319<a name="example-referral-form-codes-20319"></a></td>
          <td>Kidney Stones</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20320<a name="example-referral-form-codes-20320"></a></td>
          <td>Proteinuria</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20321<a name="example-referral-form-codes-20321"></a></td>
          <td>Suspected Glomerulonephritis/Renal Vasculitis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20322<a name="example-referral-form-codes-20322"></a></td>
          <td>Rapidly worsening kidney function, confirmed on repeat testing in absence of remediable causes</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20323<a name="example-referral-form-codes-20323"></a></td>
          <td>ACR = 60 � Persistent for = 3 months</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20324<a name="example-referral-form-codes-20324"></a></td>
          <td>eGFR &lt; 30 � Persistent for = 3 months</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20325<a name="example-referral-form-codes-20325"></a></td>
          <td>eGFR &lt; 45 and confirmed decline of = 5 within 6 months</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20326<a name="example-referral-form-codes-20326"></a></td>
          <td>eGFR &lt; 45 and age = 50 without CKD risk factors</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20327<a name="example-referral-form-codes-20327"></a></td>
          <td>5-year KFRE = 5%</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20328<a name="example-referral-form-codes-20328"></a></td>
          <td>Gross (suggest Urology referral first for those &gt; 40 years of age)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20329<a name="example-referral-form-codes-20329"></a></td>
          <td>Microscopic &gt; 10 RBC/hpf - confirmed by microscopy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20330<a name="example-referral-form-codes-20330"></a></td>
          <td>Resistant</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20331<a name="example-referral-form-codes-20331"></a></td>
          <td>Suspected Secondary Hypertension</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20332<a name="example-referral-form-codes-20332"></a></td>
          <td>Multicystic / Polycystic kidneys</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20333<a name="example-referral-form-codes-20333"></a></td>
          <td>Shrunken / Atrophic kidney</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20334<a name="example-referral-form-codes-20334"></a></td>
          <td>Metabolic work-up for recurrent stones</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20335<a name="example-referral-form-codes-20335"></a></td>
          <td>ACR = 30 without Diabetes Mellitus � Persistent for = 3 months</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20336<a name="example-referral-form-codes-20336"></a></td>
          <td>24-hour urine protein = 1 g</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20337<a name="example-referral-form-codes-20337"></a></td>
          <td>Hematuria with = 10 RBC/hpf � Confirmed by microscopy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20338<a name="example-referral-form-codes-20338"></a></td>
          <td>Urine ACR</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20339<a name="example-referral-form-codes-20339"></a></td>
          <td>eGFR</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20340<a name="example-referral-form-codes-20340"></a></td>
          <td>Potassium</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20341<a name="example-referral-form-codes-20341"></a></td>
          <td>Shoulder</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20342<a name="example-referral-form-codes-20342"></a></td>
          <td>Arm</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20343<a name="example-referral-form-codes-20343"></a></td>
          <td>Elbow</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20344<a name="example-referral-form-codes-20344"></a></td>
          <td>Forearm</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20345<a name="example-referral-form-codes-20345"></a></td>
          <td>Wrist</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20346<a name="example-referral-form-codes-20346"></a></td>
          <td>Hand</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20347<a name="example-referral-form-codes-20347"></a></td>
          <td>Spine</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20348<a name="example-referral-form-codes-20348"></a></td>
          <td>Pelvis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20349<a name="example-referral-form-codes-20349"></a></td>
          <td>Hip</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20350<a name="example-referral-form-codes-20350"></a></td>
          <td>Thigh</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20351<a name="example-referral-form-codes-20351"></a></td>
          <td>Knee</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20352<a name="example-referral-form-codes-20352"></a></td>
          <td>Leg</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20353<a name="example-referral-form-codes-20353"></a></td>
          <td>Ankle / Hindfoot</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20354<a name="example-referral-form-codes-20354"></a></td>
          <td>Midfoot / Forefoot</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20355<a name="example-referral-form-codes-20355"></a></td>
          <td>Fracture</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20356<a name="example-referral-form-codes-20356"></a></td>
          <td>Joint Instability / Subluxation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20357<a name="example-referral-form-codes-20357"></a></td>
          <td>Osteoarthritis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20358<a name="example-referral-form-codes-20358"></a></td>
          <td>Pain NYD</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20359<a name="example-referral-form-codes-20359"></a></td>
          <td>Rotator Cuff / Impingement</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20360<a name="example-referral-form-codes-20360"></a></td>
          <td>Post-traumatic arthritis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20362<a name="example-referral-form-codes-20362"></a></td>
          <td>De Quervain�s Tenosynovitis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20363<a name="example-referral-form-codes-20363"></a></td>
          <td>Ganglion Cyst</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20364<a name="example-referral-form-codes-20364"></a></td>
          <td>Dupuytren�s Contracture</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20365<a name="example-referral-form-codes-20365"></a></td>
          <td>Finger Deformity</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20366<a name="example-referral-form-codes-20366"></a></td>
          <td>Flexor Tendon Injury</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20367<a name="example-referral-form-codes-20367"></a></td>
          <td>Trigger Finger</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20368<a name="example-referral-form-codes-20368"></a></td>
          <td>Cervical Spine</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20369<a name="example-referral-form-codes-20369"></a></td>
          <td>Thoracic Spine</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20370<a name="example-referral-form-codes-20370"></a></td>
          <td>Lumbar Spine</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20371<a name="example-referral-form-codes-20371"></a></td>
          <td>Deformity / Scoliosis / Kyphosis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20372<a name="example-referral-form-codes-20372"></a></td>
          <td>Myelopathy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20373<a name="example-referral-form-codes-20373"></a></td>
          <td>Neurogenic Claudication</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20374<a name="example-referral-form-codes-20374"></a></td>
          <td>Spondylolisthesis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20375<a name="example-referral-form-codes-20375"></a></td>
          <td>Stenosis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20377<a name="example-referral-form-codes-20377"></a></td>
          <td>ACL Tear</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20378<a name="example-referral-form-codes-20378"></a></td>
          <td>Cartilage Injury</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20376<a name="example-referral-form-codes-20376"></a></td>
          <td>Knee Malalignment</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20379<a name="example-referral-form-codes-20379"></a></td>
          <td>Loose Bodies</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20380<a name="example-referral-form-codes-20380"></a></td>
          <td>Meniscal Tear</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20381<a name="example-referral-form-codes-20381"></a></td>
          <td>Multi-Ligament Injury</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20382<a name="example-referral-form-codes-20382"></a></td>
          <td>Achilles Tendinopathy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20383<a name="example-referral-form-codes-20383"></a></td>
          <td>Joint Instability</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20384<a name="example-referral-form-codes-20384"></a></td>
          <td>Bunion</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20385<a name="example-referral-form-codes-20385"></a></td>
          <td>Charcot Foot</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20386<a name="example-referral-form-codes-20386"></a></td>
          <td>Flatfoot / Pes Planus</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20387<a name="example-referral-form-codes-20387"></a></td>
          <td>Metatarsalgia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20388<a name="example-referral-form-codes-20388"></a></td>
          <td>Plantar Fasciitis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20389<a name="example-referral-form-codes-20389"></a></td>
          <td>Toe Deformity</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20390<a name="example-referral-form-codes-20390"></a></td>
          <td>CT Requisition</td>
          <td>Demande de TDM</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20391<a name="example-referral-form-codes-20391"></a></td>
          <td>MRI Requisition</td>
          <td>Demande d'IRM</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20392<a name="example-referral-form-codes-20392"></a></td>
          <td>X-Ray Requisition</td>
          <td>Demande de radiographie</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20393<a name="example-referral-form-codes-20393"></a></td>
          <td>Ultrasound Requisition</td>
          <td>Demande d'échographie</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20394<a name="example-referral-form-codes-20394"></a></td>
          <td>Bone Mineral Density Requisition</td>
          <td>Demande de densitométrie osseuse</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20395<a name="example-referral-form-codes-20395"></a></td>
          <td>Head</td>
          <td>Tête</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20396<a name="example-referral-form-codes-20396"></a></td>
          <td>Neck</td>
          <td>Cou</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20397<a name="example-referral-form-codes-20397"></a></td>
          <td>Spine</td>
          <td>Colonne vertébrale</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20398<a name="example-referral-form-codes-20398"></a></td>
          <td>Thorax</td>
          <td>Thorax</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20399<a name="example-referral-form-codes-20399"></a></td>
          <td>Abdomen Pelvis</td>
          <td>Abdomen Bassin</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20400<a name="example-referral-form-codes-20400"></a></td>
          <td>Musculoskeletal</td>
          <td>Musculosquelettique</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20401<a name="example-referral-form-codes-20401"></a></td>
          <td>Angiography</td>
          <td>Angiographie</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20403<a name="example-referral-form-codes-20403"></a></td>
          <td>Whole-Body Low-Dose (Myeloma)</td>
          <td>Corps entier faible dose (Myélome)</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20404<a name="example-referral-form-codes-20404"></a></td>
          <td>Cardiac</td>
          <td>Cardiaque</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20405<a name="example-referral-form-codes-20405"></a></td>
          <td>Biopsy</td>
          <td>Biopsie</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20406<a name="example-referral-form-codes-20406"></a></td>
          <td>Brain</td>
          <td>Cerveau</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20408<a name="example-referral-form-codes-20408"></a></td>
          <td>Facial bones</td>
          <td>Os du visage</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20409<a name="example-referral-form-codes-20409"></a></td>
          <td>Internal auditory canals</td>
          <td>Canaux auditifs internes</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20410<a name="example-referral-form-codes-20410"></a></td>
          <td>Orbits</td>
          <td>Orbites</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20411<a name="example-referral-form-codes-20411"></a></td>
          <td>Sinuses</td>
          <td>Sinus</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20412<a name="example-referral-form-codes-20412"></a></td>
          <td>Temporal bones</td>
          <td>Os temporaux</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20414<a name="example-referral-form-codes-20414"></a></td>
          <td>Soft Tissue Neck</td>
          <td>Tissus mous du cou</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20415<a name="example-referral-form-codes-20415"></a></td>
          <td>Cervical Spine</td>
          <td>Colonne cervicale</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20416<a name="example-referral-form-codes-20416"></a></td>
          <td>Thoracic Spine</td>
          <td>Colonne thoracique</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20417<a name="example-referral-form-codes-20417"></a></td>
          <td>Lumbar Spine</td>
          <td>Colonne lombaire</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20418<a name="example-referral-form-codes-20418"></a></td>
          <td>Sacrum/Coccyx</td>
          <td>Sacrum/Coccyx</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20419<a name="example-referral-form-codes-20419"></a></td>
          <td>Sacroiliac Joints</td>
          <td>Articulations sacro-iliaques</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20420<a name="example-referral-form-codes-20420"></a></td>
          <td>Chest</td>
          <td>Thorax</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20421<a name="example-referral-form-codes-20421"></a></td>
          <td>Chest High Resolution</td>
          <td>Thorax haute résolution</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20422<a name="example-referral-form-codes-20422"></a></td>
          <td>Chest Low-Dose</td>
          <td>Thorax faible dose</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20423<a name="example-referral-form-codes-20423"></a></td>
          <td>Pulmonary Embolism</td>
          <td>Embolie pulmonaire</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20425<a name="example-referral-form-codes-20425"></a></td>
          <td>Thoracic Outlet</td>
          <td>Défilé thoracique</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20426<a name="example-referral-form-codes-20426"></a></td>
          <td>Chest Abdomen Pelvis</td>
          <td>Thorax Abdomen Bassin</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20427<a name="example-referral-form-codes-20427"></a></td>
          <td>Abdomen only</td>
          <td>Abdomen seulement</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20428<a name="example-referral-form-codes-20428"></a></td>
          <td>Pelvis only</td>
          <td>Bassin seulement</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20430<a name="example-referral-form-codes-20430"></a></td>
          <td>Colonography</td>
          <td>Colonographie</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20431<a name="example-referral-form-codes-20431"></a></td>
          <td>Enterography</td>
          <td>Entérographie</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20432<a name="example-referral-form-codes-20432"></a></td>
          <td>Renal Colic</td>
          <td>Colique rénale</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20433<a name="example-referral-form-codes-20433"></a></td>
          <td>Urography</td>
          <td>Urographie</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20434<a name="example-referral-form-codes-20434"></a></td>
          <td>Shoulder</td>
          <td>Épaule</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20435<a name="example-referral-form-codes-20435"></a></td>
          <td>Humerus</td>
          <td>Humérus</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20436<a name="example-referral-form-codes-20436"></a></td>
          <td>Elbow</td>
          <td>Coude</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20437<a name="example-referral-form-codes-20437"></a></td>
          <td>Forearm</td>
          <td>Avant-bras</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20438<a name="example-referral-form-codes-20438"></a></td>
          <td>Wrist</td>
          <td>Poignet</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20439<a name="example-referral-form-codes-20439"></a></td>
          <td>Hand</td>
          <td>Main</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20440<a name="example-referral-form-codes-20440"></a></td>
          <td>Bony Pelvis</td>
          <td>Bassin osseux</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20441<a name="example-referral-form-codes-20441"></a></td>
          <td>Hip</td>
          <td>Hanche</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20442<a name="example-referral-form-codes-20442"></a></td>
          <td>Femur</td>
          <td>Fémur</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20443<a name="example-referral-form-codes-20443"></a></td>
          <td>Knee</td>
          <td>Genou</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20444<a name="example-referral-form-codes-20444"></a></td>
          <td>Tibia and Fibula</td>
          <td>Tibia et fibula</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20445<a name="example-referral-form-codes-20445"></a></td>
          <td>Ankle</td>
          <td>Cheville</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20446<a name="example-referral-form-codes-20446"></a></td>
          <td>Foot</td>
          <td>Pied</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20447<a name="example-referral-form-codes-20447"></a></td>
          <td>Head Angiography</td>
          <td>Angiographie de la tête</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20448<a name="example-referral-form-codes-20448"></a></td>
          <td>Neck Angiography</td>
          <td>Angiographie du cou</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20449<a name="example-referral-form-codes-20449"></a></td>
          <td>Chest Angiography</td>
          <td>Angiographie du thorax</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20450<a name="example-referral-form-codes-20450"></a></td>
          <td>Chest Abdomen Pelvis Angiography</td>
          <td>Angiographie thorax abdomen bassin</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20451<a name="example-referral-form-codes-20451"></a></td>
          <td>Abdomen Angiography</td>
          <td>Angiographie de l'abdomen</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20452<a name="example-referral-form-codes-20452"></a></td>
          <td>Abdomen Pelvis Angiography</td>
          <td>Angiographie abdomen bassin</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20453<a name="example-referral-form-codes-20453"></a></td>
          <td>Pelvis Angiography</td>
          <td>Angiographie du bassin</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20454<a name="example-referral-form-codes-20454"></a></td>
          <td>Upper Extremity Angiography</td>
          <td>Angiographie des membres supérieurs</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20455<a name="example-referral-form-codes-20455"></a></td>
          <td>Lower Extremity Angiography</td>
          <td>Angiographie des membres inférieurs</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20456<a name="example-referral-form-codes-20456"></a></td>
          <td>Head Venography</td>
          <td>Céphalique veineuse</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20464<a name="example-referral-form-codes-20464"></a></td>
          <td>Cardiac CT</td>
          <td>CT cardiaque</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20465<a name="example-referral-form-codes-20465"></a></td>
          <td>Coronary Angiography (CCTA)</td>
          <td>Angiographie coronarienne (CCTA)</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20466<a name="example-referral-form-codes-20466"></a></td>
          <td>Cardiac Calcium Score</td>
          <td>Score calcique cardiaque</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20467<a name="example-referral-form-codes-20467"></a></td>
          <td>Head</td>
          <td>Tête</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20468<a name="example-referral-form-codes-20468"></a></td>
          <td>Neck</td>
          <td>Cou</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20469<a name="example-referral-form-codes-20469"></a></td>
          <td>Spine</td>
          <td>Colonne vertébrale</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20470<a name="example-referral-form-codes-20470"></a></td>
          <td>Thorax</td>
          <td>Thorax</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20471<a name="example-referral-form-codes-20471"></a></td>
          <td>Abdomen</td>
          <td>Abdomen</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20472<a name="example-referral-form-codes-20472"></a></td>
          <td>Pelvis</td>
          <td>Bassin</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20473<a name="example-referral-form-codes-20473"></a></td>
          <td>Musculoskeletal</td>
          <td>Musculosquelettique</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20474<a name="example-referral-form-codes-20474"></a></td>
          <td>Angiography</td>
          <td>Angiographie</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20476<a name="example-referral-form-codes-20476"></a></td>
          <td>Breast</td>
          <td>Sein</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20477<a name="example-referral-form-codes-20477"></a></td>
          <td>Cardiac</td>
          <td>Cardiaque</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20478<a name="example-referral-form-codes-20478"></a></td>
          <td>Brain</td>
          <td>Cerveau</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20480<a name="example-referral-form-codes-20480"></a></td>
          <td>Internal auditory canals</td>
          <td>Canaux auditifs internes</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20481<a name="example-referral-form-codes-20481"></a></td>
          <td>Orbits</td>
          <td>Orbites</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20482<a name="example-referral-form-codes-20482"></a></td>
          <td>Pituitary / Sella</td>
          <td>Hypophyse / Sella</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20483<a name="example-referral-form-codes-20483"></a></td>
          <td>Sinuses</td>
          <td>Sinus</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20484<a name="example-referral-form-codes-20484"></a></td>
          <td>Temporomandibular joints</td>
          <td>Articulations temporo-mandibulaires</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20485<a name="example-referral-form-codes-20485"></a></td>
          <td>Trigeminal nerve</td>
          <td>Nerf trijumeau</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20487<a name="example-referral-form-codes-20487"></a></td>
          <td>Soft Tissue Neck</td>
          <td>Tissu mou du cou</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20488<a name="example-referral-form-codes-20488"></a></td>
          <td>Brachial plexus</td>
          <td>Plexus brachial</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20489<a name="example-referral-form-codes-20489"></a></td>
          <td>Whole Spine</td>
          <td>Colonne vertébrale entière</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20490<a name="example-referral-form-codes-20490"></a></td>
          <td>Cervical Spine</td>
          <td>Colonne cervicale</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20491<a name="example-referral-form-codes-20491"></a></td>
          <td>Thoracic Spine</td>
          <td>Colonne thoracique</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20492<a name="example-referral-form-codes-20492"></a></td>
          <td>Lumbar Spine</td>
          <td>Colonne lombaire</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20493<a name="example-referral-form-codes-20493"></a></td>
          <td>Sacrum/Coccyx</td>
          <td>Sacrum/Coccyx</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20494<a name="example-referral-form-codes-20494"></a></td>
          <td>Sacroiliac Joints</td>
          <td>Articulations sacro-iliaques</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20495<a name="example-referral-form-codes-20495"></a></td>
          <td>Chest</td>
          <td>Thorax</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20496<a name="example-referral-form-codes-20496"></a></td>
          <td>Chest wall</td>
          <td>Paroi thoracique</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20497<a name="example-referral-form-codes-20497"></a></td>
          <td>Pulmonary arteries</td>
          <td>Artères pulmonaires</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20498<a name="example-referral-form-codes-20498"></a></td>
          <td>Sternoclavicular joints</td>
          <td>Articulations sternoclaviculaires</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20499<a name="example-referral-form-codes-20499"></a></td>
          <td>Sternum</td>
          <td>Sternum</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20501<a name="example-referral-form-codes-20501"></a></td>
          <td>Thoracic Outlet</td>
          <td>Défilé thoracique</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20503<a name="example-referral-form-codes-20503"></a></td>
          <td>Abdominal wall</td>
          <td>Paroi abdominale</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20504<a name="example-referral-form-codes-20504"></a></td>
          <td>Adrenal glands</td>
          <td>Glandes surrénales</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20505<a name="example-referral-form-codes-20505"></a></td>
          <td>Biliary and pancreatic ducts</td>
          <td>Voies biliaires et pancréatiques</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20506<a name="example-referral-form-codes-20506"></a></td>
          <td>Enterography</td>
          <td>Entérographie</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20507<a name="example-referral-form-codes-20507"></a></td>
          <td>Kidneys</td>
          <td>Reins</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20508<a name="example-referral-form-codes-20508"></a></td>
          <td>Liver</td>
          <td>Foie</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20509<a name="example-referral-form-codes-20509"></a></td>
          <td>Pancreas</td>
          <td>Pancréas</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20510<a name="example-referral-form-codes-20510"></a></td>
          <td>Renal artery</td>
          <td>Artère rénale</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20511<a name="example-referral-form-codes-20511"></a></td>
          <td>Urography</td>
          <td>Urographie</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20512<a name="example-referral-form-codes-20512"></a></td>
          <td>Bladder</td>
          <td>Vessie</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20513<a name="example-referral-form-codes-20513"></a></td>
          <td>Gynecology (Uterus/ Ovaries/ Adnexal)</td>
          <td>Gynécologie (Utérus/ Ovaires/ Annexes)</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20514<a name="example-referral-form-codes-20514"></a></td>
          <td>Iliac arteries</td>
          <td>Artères iliaques</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20515<a name="example-referral-form-codes-20515"></a></td>
          <td>Piriformis</td>
          <td>Piriforme</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20516<a name="example-referral-form-codes-20516"></a></td>
          <td>Prostate</td>
          <td>Prostate</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20517<a name="example-referral-form-codes-20517"></a></td>
          <td>Rectum/ Anal</td>
          <td>Rectum/ Anal</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20518<a name="example-referral-form-codes-20518"></a></td>
          <td>Urogenital (Testicular/ Penile)</td>
          <td>Urogénital (Testiculaire/ Pénien)</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20519<a name="example-referral-form-codes-20519"></a></td>
          <td>Shoulder</td>
          <td>Épaule</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20520<a name="example-referral-form-codes-20520"></a></td>
          <td>Humerus</td>
          <td>Humérus</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20521<a name="example-referral-form-codes-20521"></a></td>
          <td>Elbow</td>
          <td>Coude</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20522<a name="example-referral-form-codes-20522"></a></td>
          <td>Forearm</td>
          <td>Avant-bras</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20523<a name="example-referral-form-codes-20523"></a></td>
          <td>Wrist</td>
          <td>Poignet</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20524<a name="example-referral-form-codes-20524"></a></td>
          <td>Hand</td>
          <td>Main</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20525<a name="example-referral-form-codes-20525"></a></td>
          <td>Finger</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20526<a name="example-referral-form-codes-20526"></a></td>
          <td>Bony Pelvis</td>
          <td>Bassins osseux</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20527<a name="example-referral-form-codes-20527"></a></td>
          <td>Hip</td>
          <td>Hanche</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20528<a name="example-referral-form-codes-20528"></a></td>
          <td>Femur / Thigh</td>
          <td>Fémur / Cuisse</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20529<a name="example-referral-form-codes-20529"></a></td>
          <td>Knee</td>
          <td>Genou</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20530<a name="example-referral-form-codes-20530"></a></td>
          <td>Tibia and Fibula</td>
          <td>Tibia et Fibula</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20531<a name="example-referral-form-codes-20531"></a></td>
          <td>Ankle</td>
          <td>Cheville</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20532<a name="example-referral-form-codes-20532"></a></td>
          <td>Foot</td>
          <td>Pied</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20533<a name="example-referral-form-codes-20533"></a></td>
          <td>Toe</td>
          <td>Orteil</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20534<a name="example-referral-form-codes-20534"></a></td>
          <td>Arthrogram</td>
          <td>Arthrogramme</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20535<a name="example-referral-form-codes-20535"></a></td>
          <td>Arthrogram</td>
          <td>Arthrogramme</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20536<a name="example-referral-form-codes-20536"></a></td>
          <td>Arthrogram</td>
          <td>Arthrogramme</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20537<a name="example-referral-form-codes-20537"></a></td>
          <td>Arthrogram</td>
          <td>Arthrogramme</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20538<a name="example-referral-form-codes-20538"></a></td>
          <td>Arthrogram</td>
          <td>Arthrogramme</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20539<a name="example-referral-form-codes-20539"></a></td>
          <td>Arthrogram</td>
          <td>Arthrogramme</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20540<a name="example-referral-form-codes-20540"></a></td>
          <td>Head Angiography</td>
          <td>Angiographie de la tête</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20541<a name="example-referral-form-codes-20541"></a></td>
          <td>Neck Angiography</td>
          <td>Angiographie du cou</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20542<a name="example-referral-form-codes-20542"></a></td>
          <td>Chest Angiography</td>
          <td>Angiographie thoracique</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20543<a name="example-referral-form-codes-20543"></a></td>
          <td>Abdomen Angiography</td>
          <td>Angiographie abdominale</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20544<a name="example-referral-form-codes-20544"></a></td>
          <td>Pelvis Angiography</td>
          <td>Angiographie pelvienne</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20545<a name="example-referral-form-codes-20545"></a></td>
          <td>Upper Extremity Angiography</td>
          <td>Angiographie des membres supérieurs</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20546<a name="example-referral-form-codes-20546"></a></td>
          <td>Lower Extremity Angiography</td>
          <td>Angiographie des membres inférieurs</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20554<a name="example-referral-form-codes-20554"></a></td>
          <td>Diagnostic</td>
          <td>Diagnostique</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20555<a name="example-referral-form-codes-20555"></a></td>
          <td>Implant</td>
          <td>Implant</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20556<a name="example-referral-form-codes-20556"></a></td>
          <td>Chest (default Chest 2 views)</td>
          <td>Thorax (par défaut Thorax 2 vues)</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20557<a name="example-referral-form-codes-20557"></a></td>
          <td>Abdomen</td>
          <td>Abdomen</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20558<a name="example-referral-form-codes-20558"></a></td>
          <td>Spine</td>
          <td>Colonne vertébrale</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20559<a name="example-referral-form-codes-20559"></a></td>
          <td>Head and Neck</td>
          <td>Tête et cou</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20560<a name="example-referral-form-codes-20560"></a></td>
          <td>Upper Extremities</td>
          <td>Membres supérieurs</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20561<a name="example-referral-form-codes-20561"></a></td>
          <td>Lower Extremities</td>
          <td>Membres inférieurs</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20562<a name="example-referral-form-codes-20562"></a></td>
          <td>Mammogram (Non-OBSP)</td>
          <td>Mammographie (Non-OBSP)</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20563<a name="example-referral-form-codes-20563"></a></td>
          <td>Bone Age</td>
          <td>Âge osseux</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20564<a name="example-referral-form-codes-20564"></a></td>
          <td>Survey</td>
          <td>Examen général</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20565<a name="example-referral-form-codes-20565"></a></td>
          <td>Gastric and Fluoroscopic imaging</td>
          <td>Imagerie gastrique et fluoroscopique</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20566<a name="example-referral-form-codes-20566"></a></td>
          <td>One view (PA)</td>
          <td>Une vue (PA)</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20567<a name="example-referral-form-codes-20567"></a></td>
          <td>Two Views (PA, Lat)</td>
          <td>Deux vues (PA, Lat)</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20568<a name="example-referral-form-codes-20568"></a></td>
          <td>Three views (PA inspiration, PA expiration, Lat)</td>
          <td>Trois vues (PA inspiration, PA expiration, Lat)</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20569<a name="example-referral-form-codes-20569"></a></td>
          <td>Sternum</td>
          <td>Sternum</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20570<a name="example-referral-form-codes-20570"></a></td>
          <td>Ribs</td>
          <td>Côtes</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20571<a name="example-referral-form-codes-20571"></a></td>
          <td>Thoracic inlet</td>
          <td>Orifice thoracique</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20572<a name="example-referral-form-codes-20572"></a></td>
          <td>Sternoclavicular Joints</td>
          <td>Articulations sternoclaviculaires</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20573<a name="example-referral-form-codes-20573"></a></td>
          <td>One view (Supine)</td>
          <td>Une vue (Décubitus)</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20574<a name="example-referral-form-codes-20574"></a></td>
          <td>One view (Upright)</td>
          <td>Une vue (Debout)</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20575<a name="example-referral-form-codes-20575"></a></td>
          <td>KUB (Kidney Ureters Bladder)</td>
          <td>KUB (Rein Uretères Vessie)</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20576<a name="example-referral-form-codes-20576"></a></td>
          <td>Cervical</td>
          <td>Cervical</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20577<a name="example-referral-form-codes-20577"></a></td>
          <td>Cervical spine flexion extension</td>
          <td>Flexion extension de la colonne cervicale</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20578<a name="example-referral-form-codes-20578"></a></td>
          <td>Thoracic</td>
          <td>Thoracique</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20579<a name="example-referral-form-codes-20579"></a></td>
          <td>Lumbar</td>
          <td>Lombaire</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20580<a name="example-referral-form-codes-20580"></a></td>
          <td>Lumbar spine flexion extension</td>
          <td>Flexion extension de la colonne lombaire</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20581<a name="example-referral-form-codes-20581"></a></td>
          <td>Sacrum</td>
          <td>Sacrum</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20582<a name="example-referral-form-codes-20582"></a></td>
          <td>Coccyx</td>
          <td>Coccyx</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20583<a name="example-referral-form-codes-20583"></a></td>
          <td>Sacroiliac joints</td>
          <td>Articulations sacro-iliaques</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20584<a name="example-referral-form-codes-20584"></a></td>
          <td>Scoliosis spine</td>
          <td>Colonne vertébrale scoliose</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20585<a name="example-referral-form-codes-20585"></a></td>
          <td>Skull</td>
          <td>Crâne</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20586<a name="example-referral-form-codes-20586"></a></td>
          <td>Orbits</td>
          <td>Orbites</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20587<a name="example-referral-form-codes-20587"></a></td>
          <td>Neck for soft tissue</td>
          <td>Cou pour les tissus mous</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20588<a name="example-referral-form-codes-20588"></a></td>
          <td>Mastoids</td>
          <td>Mastoïdes</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20589<a name="example-referral-form-codes-20589"></a></td>
          <td>Nasal bones</td>
          <td>Os nasaux</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20590<a name="example-referral-form-codes-20590"></a></td>
          <td>Facal bones</td>
          <td>Os faciaux</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20591<a name="example-referral-form-codes-20591"></a></td>
          <td>Mandible</td>
          <td>Mandibule</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20592<a name="example-referral-form-codes-20592"></a></td>
          <td>Temporomandibular joints</td>
          <td>Articulations temporo-mandibulaires</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20593<a name="example-referral-form-codes-20593"></a></td>
          <td>Sinus</td>
          <td>Sinus</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20594<a name="example-referral-form-codes-20594"></a></td>
          <td>Trauma or injury</td>
          <td>Traumatisme ou blessure</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20595<a name="example-referral-form-codes-20595"></a></td>
          <td>Eye for foreign body</td>
          <td>Œil pour corps étranger</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20596<a name="example-referral-form-codes-20596"></a></td>
          <td>Shoulder</td>
          <td>Épaule</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20597<a name="example-referral-form-codes-20597"></a></td>
          <td>Clavicle</td>
          <td>Clavicule</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20598<a name="example-referral-form-codes-20598"></a></td>
          <td>Acromioclavicular joints</td>
          <td>Articulations acromioclaviculaires</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20599<a name="example-referral-form-codes-20599"></a></td>
          <td>Scapula</td>
          <td>Omoplate</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20600<a name="example-referral-form-codes-20600"></a></td>
          <td>Humerus</td>
          <td>Humérus</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20601<a name="example-referral-form-codes-20601"></a></td>
          <td>Elbow</td>
          <td>Coude</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20602<a name="example-referral-form-codes-20602"></a></td>
          <td>Forearm</td>
          <td>Avant-bras</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20603<a name="example-referral-form-codes-20603"></a></td>
          <td>Wrist</td>
          <td>Poignet</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20604<a name="example-referral-form-codes-20604"></a></td>
          <td>Scaphoid</td>
          <td>Scaphoïde</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20605<a name="example-referral-form-codes-20605"></a></td>
          <td>Hand</td>
          <td>Main</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20606<a name="example-referral-form-codes-20606"></a></td>
          <td>Finger</td>
          <td>Doigt</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20607<a name="example-referral-form-codes-20607"></a></td>
          <td>Pelvis</td>
          <td>Bassins</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20608<a name="example-referral-form-codes-20608"></a></td>
          <td>Hip</td>
          <td>Hanche</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20609<a name="example-referral-form-codes-20609"></a></td>
          <td>Femur</td>
          <td>Fémur</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20610<a name="example-referral-form-codes-20610"></a></td>
          <td>Knee</td>
          <td>Genou</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20611<a name="example-referral-form-codes-20611"></a></td>
          <td>Patella</td>
          <td>Rotule</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20612<a name="example-referral-form-codes-20612"></a></td>
          <td>Tibia and fibula</td>
          <td>Tibia et fibula</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20613<a name="example-referral-form-codes-20613"></a></td>
          <td>Ankle</td>
          <td>Cheville</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20614<a name="example-referral-form-codes-20614"></a></td>
          <td>Foot</td>
          <td>Pied</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20615<a name="example-referral-form-codes-20615"></a></td>
          <td>Calcaneus</td>
          <td>Calcanéum</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20616<a name="example-referral-form-codes-20616"></a></td>
          <td>Toes</td>
          <td>Orteils</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20617<a name="example-referral-form-codes-20617"></a></td>
          <td>Leg length</td>
          <td>Longueur de jambe</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20618<a name="example-referral-form-codes-20618"></a></td>
          <td>Metabolic</td>
          <td>Métabolique</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20619<a name="example-referral-form-codes-20619"></a></td>
          <td>Metastatic</td>
          <td>Métastatique</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20620<a name="example-referral-form-codes-20620"></a></td>
          <td>Rheumatoid</td>
          <td>Rhumatoïde</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20621<a name="example-referral-form-codes-20621"></a></td>
          <td>Babygram</td>
          <td>Radiographie du bébé</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20622<a name="example-referral-form-codes-20622"></a></td>
          <td>Gastrointestinal tract</td>
          <td>Tube gastro-intestinal</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20623<a name="example-referral-form-codes-20623"></a></td>
          <td>Retrograde urethrogram</td>
          <td>Uréthrogramme rétrograde</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20624<a name="example-referral-form-codes-20624"></a></td>
          <td>Cystourethrogram</td>
          <td>Cystouréthrogramme</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20625<a name="example-referral-form-codes-20625"></a></td>
          <td>Hysterosalpingogram</td>
          <td>Hystérosalpingogramme</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20626<a name="example-referral-form-codes-20626"></a></td>
          <td>Sinogram</td>
          <td>Sinogramme</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20627<a name="example-referral-form-codes-20627"></a></td>
          <td>Musculoskeletal injections</td>
          <td>Injections musculosquelettiques</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20628<a name="example-referral-form-codes-20628"></a></td>
          <td>Modified barium swallow (Video fluoroscope swallowing exam)</td>
          <td>Déglutition au baryum modifiée (Examen de déglutition par fluoroscope vidéo)</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20629<a name="example-referral-form-codes-20629"></a></td>
          <td>Barium swallow</td>
          <td>Déglutition au baryum</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20630<a name="example-referral-form-codes-20630"></a></td>
          <td>Upper GI series (Esophagus, stomach and duodenum)</td>
          <td>Série GI supérieure (Œsophage, estomac et duodénum)</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20631<a name="example-referral-form-codes-20631"></a></td>
          <td>Small bowel follow through</td>
          <td>Suivi de l'intestin grêle</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20632<a name="example-referral-form-codes-20632"></a></td>
          <td>Barium enema</td>
          <td>Lavement baryté</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20633<a name="example-referral-form-codes-20633"></a></td>
          <td>Stress</td>
          <td>Stress</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20634<a name="example-referral-form-codes-20634"></a></td>
          <td>Voiding</td>
          <td>Miction</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20635<a name="example-referral-form-codes-20635"></a></td>
          <td>Abdomen</td>
          <td>Abdomen</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20636<a name="example-referral-form-codes-20636"></a></td>
          <td>Pelvis</td>
          <td>Bassins</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20637<a name="example-referral-form-codes-20637"></a></td>
          <td>Obstetrical</td>
          <td>Obstétrical</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20638<a name="example-referral-form-codes-20638"></a></td>
          <td>Neonatal and Paediatric</td>
          <td>Néonatal et pédiatrique</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20639<a name="example-referral-form-codes-20639"></a></td>
          <td>Musculoskeletal</td>
          <td>Musculosquelettique</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20640<a name="example-referral-form-codes-20640"></a></td>
          <td>Vascular</td>
          <td>Vasculaire</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20641<a name="example-referral-form-codes-20641"></a></td>
          <td>Head and Neck</td>
          <td>Tête et cou</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20642<a name="example-referral-form-codes-20642"></a></td>
          <td>Breast and Axilla</td>
          <td>Sein et aisselle</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20643<a name="example-referral-form-codes-20643"></a></td>
          <td>Complete abdomen</td>
          <td>Abdomen complet</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20644<a name="example-referral-form-codes-20644"></a></td>
          <td>Appendix</td>
          <td>Appendice</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20645<a name="example-referral-form-codes-20645"></a></td>
          <td>Gallbladder</td>
          <td>Vésicule biliaire</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20646<a name="example-referral-form-codes-20646"></a></td>
          <td>Kidney Ureters Bladder</td>
          <td>Rein Uretères Vessie</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20647<a name="example-referral-form-codes-20647"></a></td>
          <td>Liver</td>
          <td>Foie</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20648<a name="example-referral-form-codes-20648"></a></td>
          <td>Liver elastography</td>
          <td>Élastographie du foie</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20649<a name="example-referral-form-codes-20649"></a></td>
          <td>Pancreas</td>
          <td>Pancréas</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20650<a name="example-referral-form-codes-20650"></a></td>
          <td>Portal hypertension</td>
          <td>Hypertension portale</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20651<a name="example-referral-form-codes-20651"></a></td>
          <td>Renal</td>
          <td>Rénal</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20652<a name="example-referral-form-codes-20652"></a></td>
          <td>Right upper quadrant</td>
          <td>Quadrant supérieur droit</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20653<a name="example-referral-form-codes-20653"></a></td>
          <td>Spleen</td>
          <td>Rate</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20654<a name="example-referral-form-codes-20654"></a></td>
          <td>Abdomen contrast</td>
          <td>Abdomen avec contraste</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20655<a name="example-referral-form-codes-20655"></a></td>
          <td>Abdominal wall</td>
          <td>Paroi abdominale</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20656<a name="example-referral-form-codes-20656"></a></td>
          <td>Complete pelvis</td>
          <td>Bassins complet</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20657<a name="example-referral-form-codes-20657"></a></td>
          <td>Pelvis transabdominal</td>
          <td>Bassins transabdominal</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20658<a name="example-referral-form-codes-20658"></a></td>
          <td>Female pelvis (transvaginal)</td>
          <td>Bassins féminin (transvaginal)</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20659<a name="example-referral-form-codes-20659"></a></td>
          <td>Follicular monitoring</td>
          <td>Surveillance folliculaire</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20660<a name="example-referral-form-codes-20660"></a></td>
          <td>Limited non-pregnancy (for IUD insertion placement check)</td>
          <td>Non-grossesse limitée (pour vérification de l'insertion du DIU)</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20661<a name="example-referral-form-codes-20661"></a></td>
          <td>Saline Infusion Sonohysterography</td>
          <td>Sonohystérographie par perfusion de sérum physiologique</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20662<a name="example-referral-form-codes-20662"></a></td>
          <td>Male pelvis (Transrectal)</td>
          <td>Bassins masculin (transrectal)</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20663<a name="example-referral-form-codes-20663"></a></td>
          <td>Prostate</td>
          <td>Prostate</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20664<a name="example-referral-form-codes-20664"></a></td>
          <td>Penile</td>
          <td>Pénien</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20665<a name="example-referral-form-codes-20665"></a></td>
          <td>Testicles/Scrotum</td>
          <td>Testicules/Scrotum</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20666<a name="example-referral-form-codes-20666"></a></td>
          <td>Bladder</td>
          <td>Vessie</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20667<a name="example-referral-form-codes-20667"></a></td>
          <td>Groin</td>
          <td>Aine</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20668<a name="example-referral-form-codes-20668"></a></td>
          <td>Singleton</td>
          <td>Grossesse unique</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20669<a name="example-referral-form-codes-20669"></a></td>
          <td>Twins</td>
          <td>Jumeaux</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20670<a name="example-referral-form-codes-20670"></a></td>
          <td>Triplets</td>
          <td>Triplés</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20671<a name="example-referral-form-codes-20671"></a></td>
          <td>Unknown</td>
          <td>Inconnu</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20672<a name="example-referral-form-codes-20672"></a></td>
          <td>Dating (&lt;16 weeks)</td>
          <td>Datation (&lt;16 semaines)</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20673<a name="example-referral-form-codes-20673"></a></td>
          <td>Prenatal screening (NT/eFTS) 11-14 weeks</td>
          <td>Dépistage prénatal (NT/eFTS) 11-14 semaines</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20674<a name="example-referral-form-codes-20674"></a></td>
          <td>Anatomy (20 week scan)</td>
          <td>Anatomie (échographie de 20 semaines)</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20675<a name="example-referral-form-codes-20675"></a></td>
          <td>2nd or 3rd trimester scan</td>
          <td>Échographie du 2e ou 3e trimestre</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20676<a name="example-referral-form-codes-20676"></a></td>
          <td>Biophysical profile</td>
          <td>Profil bio-physique</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20677<a name="example-referral-form-codes-20677"></a></td>
          <td>Growth</td>
          <td>Croissance</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20678<a name="example-referral-form-codes-20678"></a></td>
          <td>Cervical length</td>
          <td>Longueur cervicale</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20745<a name="example-referral-form-codes-20745"></a></td>
          <td>With transvaginal</td>
          <td>Avec transvaginal</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20679<a name="example-referral-form-codes-20679"></a></td>
          <td>Multi-gestational study</td>
          <td>Étude multi-gestationnelle</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20680<a name="example-referral-form-codes-20680"></a></td>
          <td>High risk pregnancy</td>
          <td>Grossesse à haut risque</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20681<a name="example-referral-form-codes-20681"></a></td>
          <td>Uterine artery doppler studies</td>
          <td>Études Doppler de l'artère utérine</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20682<a name="example-referral-form-codes-20682"></a></td>
          <td>Umbilical artery doppler studies</td>
          <td>Études Doppler de l'artère ombilicale</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20683<a name="example-referral-form-codes-20683"></a></td>
          <td>Fetal doppler</td>
          <td>Doppler fœtal</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20684<a name="example-referral-form-codes-20684"></a></td>
          <td>Report sex</td>
          <td>Indiquer le sexe</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">20685<a name="example-referral-form-codes-20685"></a></td>
          <td>1st Trimester</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20686<a name="example-referral-form-codes-20686"></a></td>
          <td>2nd and 3rd Trimester</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20687<a name="example-referral-form-codes-20687"></a></td>
          <td>Pylorus</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20688<a name="example-referral-form-codes-20688"></a></td>
          <td>Spine</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20689<a name="example-referral-form-codes-20689"></a></td>
          <td>Brain</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20690<a name="example-referral-form-codes-20690"></a></td>
          <td>Hips</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20691<a name="example-referral-form-codes-20691"></a></td>
          <td>Pylorus and Hypertrophic Pyloric Stenosis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20692<a name="example-referral-form-codes-20692"></a></td>
          <td>Bowel</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20693<a name="example-referral-form-codes-20693"></a></td>
          <td>Foot</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20694<a name="example-referral-form-codes-20694"></a></td>
          <td>Plantar fascia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20695<a name="example-referral-form-codes-20695"></a></td>
          <td>Ankle</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20696<a name="example-referral-form-codes-20696"></a></td>
          <td>Achilles</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20697<a name="example-referral-form-codes-20697"></a></td>
          <td>Calf/Lower leg/Gastrocnemius</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20698<a name="example-referral-form-codes-20698"></a></td>
          <td>Knee</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20699<a name="example-referral-form-codes-20699"></a></td>
          <td>Patellar tendon</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20700<a name="example-referral-form-codes-20700"></a></td>
          <td>Popliteal fossa</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20701<a name="example-referral-form-codes-20701"></a></td>
          <td>Quadriceps tendon</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20702<a name="example-referral-form-codes-20702"></a></td>
          <td>Thigh/Hamstrings</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20703<a name="example-referral-form-codes-20703"></a></td>
          <td>Hip</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20704<a name="example-referral-form-codes-20704"></a></td>
          <td>Gluteal region</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20705<a name="example-referral-form-codes-20705"></a></td>
          <td>Hand</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20706<a name="example-referral-form-codes-20706"></a></td>
          <td>Wrist</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20707<a name="example-referral-form-codes-20707"></a></td>
          <td>Carpal tunnel</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20708<a name="example-referral-form-codes-20708"></a></td>
          <td>Forearm</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20709<a name="example-referral-form-codes-20709"></a></td>
          <td>Elbow</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20710<a name="example-referral-form-codes-20710"></a></td>
          <td>Biceps</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20711<a name="example-referral-form-codes-20711"></a></td>
          <td>Triceps</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20712<a name="example-referral-form-codes-20712"></a></td>
          <td>Shoulders</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20713<a name="example-referral-form-codes-20713"></a></td>
          <td>Rotator cuff</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20714<a name="example-referral-form-codes-20714"></a></td>
          <td>Toe(s)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20715<a name="example-referral-form-codes-20715"></a></td>
          <td>Finger(s)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20716<a name="example-referral-form-codes-20716"></a></td>
          <td>Palpable masses</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20717<a name="example-referral-form-codes-20717"></a></td>
          <td>Foreign body</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20718<a name="example-referral-form-codes-20718"></a></td>
          <td>Upper extremity arterial</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20719<a name="example-referral-form-codes-20719"></a></td>
          <td>Upper extremity venous</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20720<a name="example-referral-form-codes-20720"></a></td>
          <td>Lower extremity arterial</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20721<a name="example-referral-form-codes-20721"></a></td>
          <td>Lower extremity venous thrombosis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20722<a name="example-referral-form-codes-20722"></a></td>
          <td>Lower extremity venous reflux</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20723<a name="example-referral-form-codes-20723"></a></td>
          <td>Abdominal aortic aneurysm screen</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20724<a name="example-referral-form-codes-20724"></a></td>
          <td>Ankle brachial index</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20725<a name="example-referral-form-codes-20725"></a></td>
          <td>Arterial venous fistula</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20726<a name="example-referral-form-codes-20726"></a></td>
          <td>Carotid</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20727<a name="example-referral-form-codes-20727"></a></td>
          <td>Inferior vena cava</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20728<a name="example-referral-form-codes-20728"></a></td>
          <td>Portal vein</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20729<a name="example-referral-form-codes-20729"></a></td>
          <td>Renal arteries</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20730<a name="example-referral-form-codes-20730"></a></td>
          <td>Superior mesenteric artery (SMA)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20731<a name="example-referral-form-codes-20731"></a></td>
          <td>Temporal arteries</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20732<a name="example-referral-form-codes-20732"></a></td>
          <td>Venous mapping</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20733<a name="example-referral-form-codes-20733"></a></td>
          <td>Neck/Salivary gland</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20734<a name="example-referral-form-codes-20734"></a></td>
          <td>Lymph nodes</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20735<a name="example-referral-form-codes-20735"></a></td>
          <td>Thyroid</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20736<a name="example-referral-form-codes-20736"></a></td>
          <td>Breast</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20737<a name="example-referral-form-codes-20737"></a></td>
          <td>Axilla</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20738<a name="example-referral-form-codes-20738"></a></td>
          <td>Chest</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20739<a name="example-referral-form-codes-20739"></a></td>
          <td>Chest wall (mass)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20740<a name="example-referral-form-codes-20740"></a></td>
          <td>Soft tissue</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20741<a name="example-referral-form-codes-20741"></a></td>
          <td>Baseline</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20742<a name="example-referral-form-codes-20742"></a></td>
          <td>Low Risk</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20743<a name="example-referral-form-codes-20743"></a></td>
          <td>High Risk</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20748<a name="example-referral-form-codes-20748"></a></td>
          <td>Breast</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20749<a name="example-referral-form-codes-20749"></a></td>
          <td>Burns and Sequelae</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20750<a name="example-referral-form-codes-20750"></a></td>
          <td>Congenital Conditions</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20751<a name="example-referral-form-codes-20751"></a></td>
          <td>Facial Trauma and Reconstruction</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20752<a name="example-referral-form-codes-20752"></a></td>
          <td>Gender-Affirming Surgery</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20753<a name="example-referral-form-codes-20753"></a></td>
          <td>Hand and Upper Limb</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20754<a name="example-referral-form-codes-20754"></a></td>
          <td>Peripheral Nerve, Carpal Tunnel Syndrome, and Brachial Plexus</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20755<a name="example-referral-form-codes-20755"></a></td>
          <td>Skin Lesions and Skin Cancer</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20756<a name="example-referral-form-codes-20756"></a></td>
          <td>Soft Tissue Tumours</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20757<a name="example-referral-form-codes-20757"></a></td>
          <td>Wound - Acute</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20758<a name="example-referral-form-codes-20758"></a></td>
          <td>Wound - Chronic / Complex</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20759<a name="example-referral-form-codes-20759"></a></td>
          <td>Breast Reduction</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20760<a name="example-referral-form-codes-20760"></a></td>
          <td>Gynecomastia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20761<a name="example-referral-form-codes-20761"></a></td>
          <td>Post-Mastectomy Reconstruction</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20762<a name="example-referral-form-codes-20762"></a></td>
          <td>Revision of Prior Breast-Surgery</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20763<a name="example-referral-form-codes-20763"></a></td>
          <td>Acute Burns</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20764<a name="example-referral-form-codes-20764"></a></td>
          <td>Burn Scar Contracture</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20765<a name="example-referral-form-codes-20765"></a></td>
          <td>Non-Healing Burn Wounds</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20766<a name="example-referral-form-codes-20766"></a></td>
          <td>Scar Revision</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20767<a name="example-referral-form-codes-20767"></a></td>
          <td>Date of Injury / Onset</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20768<a name="example-referral-form-codes-20768"></a></td>
          <td>Cleft Lip / Palate</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20769<a name="example-referral-form-codes-20769"></a></td>
          <td>Craniofacial Anomalies</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20770<a name="example-referral-form-codes-20770"></a></td>
          <td>Ear Anomalies</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20771<a name="example-referral-form-codes-20771"></a></td>
          <td>Hand Anomalies</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20772<a name="example-referral-form-codes-20772"></a></td>
          <td>Vascular Anomaly / Malformation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20773<a name="example-referral-form-codes-20773"></a></td>
          <td>Acute Facial Fractures</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20774<a name="example-referral-form-codes-20774"></a></td>
          <td>Acute Soft Tissue Injuries</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20775<a name="example-referral-form-codes-20775"></a></td>
          <td>Reconstruction After Trauma</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20776<a name="example-referral-form-codes-20776"></a></td>
          <td>Chest (Top) Surgery</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20777<a name="example-referral-form-codes-20777"></a></td>
          <td>Facial Gender-Affirming Surgery</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20778<a name="example-referral-form-codes-20778"></a></td>
          <td>Genital (Bottom) Surgery</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20780<a name="example-referral-form-codes-20780"></a></td>
          <td>Fracture - Acute</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20781<a name="example-referral-form-codes-20781"></a></td>
          <td>Hand Osteoarthritis (with deformity/pain/loss of function)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20782<a name="example-referral-form-codes-20782"></a></td>
          <td>Malunion / Non-union of Fractures</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20783<a name="example-referral-form-codes-20783"></a></td>
          <td>Tendon Injury - Acute</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20785<a name="example-referral-form-codes-20785"></a></td>
          <td>Brachial Plexus - Congenital Condition</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20786<a name="example-referral-form-codes-20786"></a></td>
          <td>Brachial Plexus - Traumatic Injury</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20788<a name="example-referral-form-codes-20788"></a></td>
          <td>Cubital Tunnel Syndrome</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20789<a name="example-referral-form-codes-20789"></a></td>
          <td>Peripheral Nerve Injury</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20790<a name="example-referral-form-codes-20790"></a></td>
          <td>Peripheral Nerve Tumour</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20791<a name="example-referral-form-codes-20791"></a></td>
          <td>Basal Cell Carcinoma</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20792<a name="example-referral-form-codes-20792"></a></td>
          <td>Squamous Cell Carcinoma</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20794<a name="example-referral-form-codes-20794"></a></td>
          <td>Benign or Symptomatic Lesion(s) (e.g. epidermal cysts, superficial lipomas)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20796<a name="example-referral-form-codes-20796"></a></td>
          <td>Post-Cancer Reconstruction</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20798<a name="example-referral-form-codes-20798"></a></td>
          <td>Soft Tissue Sarcoma</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20800<a name="example-referral-form-codes-20800"></a></td>
          <td>Complex Wound (e.g., mixed etiology, non-healing, exposed structures)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20801<a name="example-referral-form-codes-20801"></a></td>
          <td>Diabetic / Ischemic Foot Ulcer</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20802<a name="example-referral-form-codes-20802"></a></td>
          <td>Pressure Injury</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20803<a name="example-referral-form-codes-20803"></a></td>
          <td>Surgical Wound - Non-Healing</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20804<a name="example-referral-form-codes-20804"></a></td>
          <td>Venous Leg Ulcer</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20805<a name="example-referral-form-codes-20805"></a></td>
          <td>Anxiety or Panic Symptoms</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20806<a name="example-referral-form-codes-20806"></a></td>
          <td>Attention, Focus or Cognitive Processing Problems</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20807<a name="example-referral-form-codes-20807"></a></td>
          <td>Behavioural Addictions (e.g., gambling, gaming, internet use, sexual)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20808<a name="example-referral-form-codes-20808"></a></td>
          <td>Bipolar / Mania Symptoms</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20809<a name="example-referral-form-codes-20809"></a></td>
          <td>Dementia-Related Behaviours</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20810<a name="example-referral-form-codes-20810"></a></td>
          <td>Depression Symptoms or Low Mood</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20811<a name="example-referral-form-codes-20811"></a></td>
          <td>Eating Concerns (e.g., restricted or binge eating)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20812<a name="example-referral-form-codes-20812"></a></td>
          <td>Emotional Dysregulation (e.g., anger, aggression, mood swings)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20813<a name="example-referral-form-codes-20813"></a></td>
          <td>Hyperactivity or Impulsivity</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20814<a name="example-referral-form-codes-20814"></a></td>
          <td>Intellectual Disability</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20815<a name="example-referral-form-codes-20815"></a></td>
          <td>Memory Concerns</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20816<a name="example-referral-form-codes-20816"></a></td>
          <td>Neurodevelopmental Concerns (e.g., autism-spectrum, ADHD)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20817<a name="example-referral-form-codes-20817"></a></td>
          <td>Obsessions or Compulsions</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20818<a name="example-referral-form-codes-20818"></a></td>
          <td>Personality-Related Concerns (e.g., unstable relationships, chronic conflict with others)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20819<a name="example-referral-form-codes-20819"></a></td>
          <td>Psychotic Symptoms (e.g., hallucinations, delusions, etc.)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20820<a name="example-referral-form-codes-20820"></a></td>
          <td>Substance Use Concerns</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20821<a name="example-referral-form-codes-20821"></a></td>
          <td>Trauma-Related Symptoms / PTSD (e.g., hypervigilance, flashbacks)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20822<a name="example-referral-form-codes-20822"></a></td>
          <td>Height (cm)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20823<a name="example-referral-form-codes-20823"></a></td>
          <td>Weight (kg)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20824<a name="example-referral-form-codes-20824"></a></td>
          <td>BMI</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20825<a name="example-referral-form-codes-20825"></a></td>
          <td>Homicidal Ideation / Threats</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20826<a name="example-referral-form-codes-20826"></a></td>
          <td>Self-Harm Behaviours</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20827<a name="example-referral-form-codes-20827"></a></td>
          <td>Suicidal Ideation or Attempt</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20828<a name="example-referral-form-codes-20828"></a></td>
          <td>Violence or Aggression</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20829<a name="example-referral-form-codes-20829"></a></td>
          <td>Housing Instability</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20830<a name="example-referral-form-codes-20830"></a></td>
          <td>Legal Involvement / History</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20832<a name="example-referral-form-codes-20832"></a></td>
          <td>Behavioural Addictions (e.g., gambling, internet use, gaming, sexual)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20836<a name="example-referral-form-codes-20836"></a></td>
          <td>Difficulty coping with life stressors (e.g. grief, loss)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20841<a name="example-referral-form-codes-20841"></a></td>
          <td>Psychotic Symptoms</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20844<a name="example-referral-form-codes-20844"></a></td>
          <td>Current Weight (kgs)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20845<a name="example-referral-form-codes-20845"></a></td>
          <td>Current Weight (lbs)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20846<a name="example-referral-form-codes-20846"></a></td>
          <td>Current Height (cm)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20848<a name="example-referral-form-codes-20848"></a></td>
          <td>Blood Pressure</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20849<a name="example-referral-form-codes-20849"></a></td>
          <td>Heart Rate</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20850<a name="example-referral-form-codes-20850"></a></td>
          <td>Date of LMP</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20851<a name="example-referral-form-codes-20851"></a></td>
          <td>Food Intake Restrictions</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20852<a name="example-referral-form-codes-20852"></a></td>
          <td>Binge Eating</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20853<a name="example-referral-form-codes-20853"></a></td>
          <td>Induced Vomiting</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20854<a name="example-referral-form-codes-20854"></a></td>
          <td>Laxative Use</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20855<a name="example-referral-form-codes-20855"></a></td>
          <td>Exercise Quantity (per week)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20856<a name="example-referral-form-codes-20856"></a></td>
          <td>Chewing and Spitting</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20857<a name="example-referral-form-codes-20857"></a></td>
          <td>Diet Medications</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20858<a name="example-referral-form-codes-20858"></a></td>
          <td>First Episode Psychosis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20859<a name="example-referral-form-codes-20859"></a></td>
          <td>Case Management</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20860<a name="example-referral-form-codes-20860"></a></td>
          <td>Counselling / Psychotherapy Services</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20861<a name="example-referral-form-codes-20861"></a></td>
          <td>Psychiatric Consultation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20862<a name="example-referral-form-codes-20862"></a></td>
          <td>Diagnostic Clarification</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20863<a name="example-referral-form-codes-20863"></a></td>
          <td>Interventional Psychiatry</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20864<a name="example-referral-form-codes-20864"></a></td>
          <td>Medication / Treatment Recommendations</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20865<a name="example-referral-form-codes-20865"></a></td>
          <td>Electroconvulsive therapy (ECT)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20866<a name="example-referral-form-codes-20866"></a></td>
          <td>Repetitive Transcranial Magnetic Stimulation (rTMS)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20867<a name="example-referral-form-codes-20867"></a></td>
          <td>Family Support Services</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20868<a name="example-referral-form-codes-20868"></a></td>
          <td>Peer Support Services</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20869<a name="example-referral-form-codes-20869"></a></td>
          <td>Supportive Housing</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20870<a name="example-referral-form-codes-20870"></a></td>
          <td>Bed-Based Addiction Treatment (formerly known as Residential Addiction Services)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20871<a name="example-referral-form-codes-20871"></a></td>
          <td>Substance Use / Addiction Treatment</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20872<a name="example-referral-form-codes-20872"></a></td>
          <td>Stabilization on Opioid Agonist Therapy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20873<a name="example-referral-form-codes-20873"></a></td>
          <td>Withdrawal Management</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20874<a name="example-referral-form-codes-20874"></a></td>
          <td>Court Support</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20875<a name="example-referral-form-codes-20875"></a></td>
          <td>Possible Safety Concern to Others (e.g. aggression, homicidal threats or ideation)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20879<a name="example-referral-form-codes-20879"></a></td>
          <td>Legal Involvement / Court Orders (e.g. current charges, probation, parole, CTO/ORB conditions)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20880<a name="example-referral-form-codes-20880"></a></td>
          <td>Bone and Joint Infections</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20881<a name="example-referral-form-codes-20881"></a></td>
          <td>Clostridioides difficile (C. diff)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20882<a name="example-referral-form-codes-20882"></a></td>
          <td>Endocarditis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20883<a name="example-referral-form-codes-20883"></a></td>
          <td>Fever of Unknown Origin (FUO)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20884<a name="example-referral-form-codes-20884"></a></td>
          <td>HIV</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20885<a name="example-referral-form-codes-20885"></a></td>
          <td>Intra-Abdominal or Pelvic Infections</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20886<a name="example-referral-form-codes-20886"></a></td>
          <td>Lung Infections</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20887<a name="example-referral-form-codes-20887"></a></td>
          <td>Sexually Transmitted Infections (STIs)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20888<a name="example-referral-form-codes-20888"></a></td>
          <td>Skin and Soft Tissue Infections (SSTIs)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20889<a name="example-referral-form-codes-20889"></a></td>
          <td>Tick-borne Infections</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20890<a name="example-referral-form-codes-20890"></a></td>
          <td>Tropical and Parasitic Diseases</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20891<a name="example-referral-form-codes-20891"></a></td>
          <td>Tuberculosis (TB)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20892<a name="example-referral-form-codes-20892"></a></td>
          <td>Urinary Tract Infection (UTIs)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20893<a name="example-referral-form-codes-20893"></a></td>
          <td>Viral Hepatitis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20894<a name="example-referral-form-codes-20894"></a></td>
          <td>Osteomyelitis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20895<a name="example-referral-form-codes-20895"></a></td>
          <td>Prosthetic Joint Infection</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20896<a name="example-referral-form-codes-20896"></a></td>
          <td>Septic Arthritis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20897<a name="example-referral-form-codes-20897"></a></td>
          <td>Spinal Infections</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20898<a name="example-referral-form-codes-20898"></a></td>
          <td>HIV - New Diagnosis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20899<a name="example-referral-form-codes-20899"></a></td>
          <td>HIV - Ongoing Care</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20900<a name="example-referral-form-codes-20900"></a></td>
          <td>PrEP (Pre-Exposure Prophylaxis)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20901<a name="example-referral-form-codes-20901"></a></td>
          <td>PEP (Post-Exposure Prophylaxis)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20903<a name="example-referral-form-codes-20903"></a></td>
          <td>Cellulitis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20904<a name="example-referral-form-codes-20904"></a></td>
          <td>Diabetic Foot Infection</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20905<a name="example-referral-form-codes-20905"></a></td>
          <td>Malaria</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20906<a name="example-referral-form-codes-20906"></a></td>
          <td>Active TB - Confirmed</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20907<a name="example-referral-form-codes-20907"></a></td>
          <td>Active TB -� Suspected</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20908<a name="example-referral-form-codes-20908"></a></td>
          <td>Latent TB Infection</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20909<a name="example-referral-form-codes-20909"></a></td>
          <td>Active drug and/or alcohol addiction</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20910<a name="example-referral-form-codes-20910"></a></td>
          <td>Active treatment for a major/life-threatening cancer (e.g. chemotherapy, radiation)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20911<a name="example-referral-form-codes-20911"></a></td>
          <td>Significant psychiatric illness that is inadequately treated</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20912<a name="example-referral-form-codes-20912"></a></td>
          <td>Patient &gt;18 years old</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20913<a name="example-referral-form-codes-20913"></a></td>
          <td>Patient has an Ontario Health Card OR is a resident of Ontario and meets one of the following�</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20915<a name="example-referral-form-codes-20915"></a></td>
          <td>Weight (kgs)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20916<a name="example-referral-form-codes-20916"></a></td>
          <td>Height (ft)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20917<a name="example-referral-form-codes-20917"></a></td>
          <td>Height (in)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20918<a name="example-referral-form-codes-20918"></a></td>
          <td>Weight (lbs)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20920<a name="example-referral-form-codes-20920"></a></td>
          <td>Previously had bariatric surgery</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20921<a name="example-referral-form-codes-20921"></a></td>
          <td>Surgical complications</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20922<a name="example-referral-form-codes-20922"></a></td>
          <td>Weight regain (&gt;15% increase)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20923<a name="example-referral-form-codes-20923"></a></td>
          <td>Idiopathic intracranial hypertension</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20924<a name="example-referral-form-codes-20924"></a></td>
          <td>Coronary heart disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20925<a name="example-referral-form-codes-20925"></a></td>
          <td>Type 2 diabetes</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20927<a name="example-referral-form-codes-20927"></a></td>
          <td>Diagnosed sleep apnea</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20929<a name="example-referral-form-codes-20929"></a></td>
          <td>Renal disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20930<a name="example-referral-form-codes-20930"></a></td>
          <td>Surgical Program</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20931<a name="example-referral-form-codes-20931"></a></td>
          <td>Medical Program</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20932<a name="example-referral-form-codes-20932"></a></td>
          <td>Pilot Metabolic Surgical Program at St. Joseph�s Healthcare Hamilton</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20933<a name="example-referral-form-codes-20933"></a></td>
          <td>Optometrist / Ophthalmologist</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20934<a name="example-referral-form-codes-20934"></a></td>
          <td>Primary Care</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20935<a name="example-referral-form-codes-20935"></a></td>
          <td>Clinical Optometry/Ophthalmology Report attached</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20936<a name="example-referral-form-codes-20936"></a></td>
          <td>Right Eye (OD)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20937<a name="example-referral-form-codes-20937"></a></td>
          <td>Left Eye (OS)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20938<a name="example-referral-form-codes-20938"></a></td>
          <td>Both Eyes (OU)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20939<a name="example-referral-form-codes-20939"></a></td>
          <td>Optometry / Ophthalmology report attached including Best Corrected Visual Acuity (BCVA) and Past Ocular History</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20940<a name="example-referral-form-codes-20940"></a></td>
          <td>Right Eye</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20941<a name="example-referral-form-codes-20941"></a></td>
          <td>Right Eye BCVA 20/</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20942<a name="example-referral-form-codes-20942"></a></td>
          <td>Left Eye</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20943<a name="example-referral-form-codes-20943"></a></td>
          <td>Left Eye BCVA 20/</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20944<a name="example-referral-form-codes-20944"></a></td>
          <td>History of Ocular Pathologies</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20945<a name="example-referral-form-codes-20945"></a></td>
          <td>History of Diabetes</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20946<a name="example-referral-form-codes-20946"></a></td>
          <td>Right Eye (mmHg)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20947<a name="example-referral-form-codes-20947"></a></td>
          <td>Left Eye (mmHg)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20948<a name="example-referral-form-codes-20948"></a></td>
          <td>Does the patient wear contact lenses?</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20949<a name="example-referral-form-codes-20949"></a></td>
          <td>Soft</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20950<a name="example-referral-form-codes-20950"></a></td>
          <td>Rigid Gas Permeable</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20951<a name="example-referral-form-codes-20951"></a></td>
          <td>Does the patient wear prism in their spectacles?</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20952<a name="example-referral-form-codes-20952"></a></td>
          <td>Right Eye (prism)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20953<a name="example-referral-form-codes-20953"></a></td>
          <td>Left Eye (prism)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20954<a name="example-referral-form-codes-20954"></a></td>
          <td>Has the patient had previous corneal refractive surgery?</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20955<a name="example-referral-form-codes-20955"></a></td>
          <td>LASIK</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20956<a name="example-referral-form-codes-20956"></a></td>
          <td>PRK</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20957<a name="example-referral-form-codes-20957"></a></td>
          <td>RK</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20958<a name="example-referral-form-codes-20958"></a></td>
          <td>Has the patient had previous eye surgery or laser treatment?</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20962<a name="example-referral-form-codes-20962"></a></td>
          <td>Adrenal Gland Disorders</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20963<a name="example-referral-form-codes-20963"></a></td>
          <td>Diabetes</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20964<a name="example-referral-form-codes-20964"></a></td>
          <td>Dyslipidemia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20965<a name="example-referral-form-codes-20965"></a></td>
          <td>Male Hypogonadism</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20966<a name="example-referral-form-codes-20966"></a></td>
          <td>Menopause</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20967<a name="example-referral-form-codes-20967"></a></td>
          <td>Oligomenorrhea / Amenorrhea</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20968<a name="example-referral-form-codes-20968"></a></td>
          <td>Osteoporosis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20969<a name="example-referral-form-codes-20969"></a></td>
          <td>Parathyroid or Calcium Disorders</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20970<a name="example-referral-form-codes-20970"></a></td>
          <td>Pituitary Gland Disorders</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20972<a name="example-referral-form-codes-20972"></a></td>
          <td>Thyroid Disorders</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20973<a name="example-referral-form-codes-20973"></a></td>
          <td>Transgender (Gender Affirming Hormone Therapy)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20974<a name="example-referral-form-codes-20974"></a></td>
          <td>Weight Management / Metabolic Disorders</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20975<a name="example-referral-form-codes-20975"></a></td>
          <td>Type 1 Diabetes</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20978<a name="example-referral-form-codes-20978"></a></td>
          <td>New</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20979<a name="example-referral-form-codes-20979"></a></td>
          <td>&lt;=6 months ago</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20980<a name="example-referral-form-codes-20980"></a></td>
          <td>&gt; 6 months ago</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20977<a name="example-referral-form-codes-20977"></a></td>
          <td>Patient on insulin</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20981<a name="example-referral-form-codes-20981"></a></td>
          <td>Chemotherapy - current or planned</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20982<a name="example-referral-form-codes-20982"></a></td>
          <td>Diabetic Ketoacidosis - recent hospitalization</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20983<a name="example-referral-form-codes-20983"></a></td>
          <td>Foot ulcer(s) - active or recurring</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20984<a name="example-referral-form-codes-20984"></a></td>
          <td>Glucocorticoids - high doses with recent or anticipated initiation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20985<a name="example-referral-form-codes-20985"></a></td>
          <td>HbA1c &gt;10%</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20986<a name="example-referral-form-codes-20986"></a></td>
          <td>Hypoglycemia - severe and recent episode requiring assistance</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20987<a name="example-referral-form-codes-20987"></a></td>
          <td>Myocardial infarction or Stroke - recent event with inadequate control</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20988<a name="example-referral-form-codes-20988"></a></td>
          <td>Optimization required prior to procedure/surgery - Urgent</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20989<a name="example-referral-form-codes-20989"></a></td>
          <td>Transplant within last 6 months</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20990<a name="example-referral-form-codes-20990"></a></td>
          <td>HbA1C</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20991<a name="example-referral-form-codes-20991"></a></td>
          <td>Triglycerides &gt; 10 mmol/L</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20992<a name="example-referral-form-codes-20992"></a></td>
          <td>Atypical femur fracture</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20993<a name="example-referral-form-codes-20993"></a></td>
          <td>Fragility fracture - within last year</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20994<a name="example-referral-form-codes-20994"></a></td>
          <td>Glucocorticoids - Currently on prolonged high-dose</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20995<a name="example-referral-form-codes-20995"></a></td>
          <td>Glucocorticoids - Planned start of prolonged high-dose</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20996<a name="example-referral-form-codes-20996"></a></td>
          <td>Acromegaly suspected (clinically or high IGF-1/growth hormone)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20997<a name="example-referral-form-codes-20997"></a></td>
          <td>Cushings disease suspected (clinically or lab testing)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20998<a name="example-referral-form-codes-20998"></a></td>
          <td>Dysfunction - decreased pituitary function (include labs)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">20999<a name="example-referral-form-codes-20999"></a></td>
          <td>Prolactin &gt; 200 ug/L</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21000<a name="example-referral-form-codes-21000"></a></td>
          <td>Sellar lesion &gt; 1 cm - confirmed on MRI or CT</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21001<a name="example-referral-form-codes-21001"></a></td>
          <td>Visual fields compromised</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21002<a name="example-referral-form-codes-21002"></a></td>
          <td>Hyperthyroidism</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21003<a name="example-referral-form-codes-21003"></a></td>
          <td>Hypothyroidism</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21004<a name="example-referral-form-codes-21004"></a></td>
          <td>Thyroid Nodule</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21005<a name="example-referral-form-codes-21005"></a></td>
          <td>Thyroid Cancer</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21006<a name="example-referral-form-codes-21006"></a></td>
          <td>TSH</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21007<a name="example-referral-form-codes-21007"></a></td>
          <td>Site-Specific Suspicion of Cancer Presentations</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21008<a name="example-referral-form-codes-21008"></a></td>
          <td>Non-Site Specific Suspicion of Cancer Presentations</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21009<a name="example-referral-form-codes-21009"></a></td>
          <td>Breast</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21010<a name="example-referral-form-codes-21010"></a></td>
          <td>Chest / Lung</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21011<a name="example-referral-form-codes-21011"></a></td>
          <td>Genitourinary</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21012<a name="example-referral-form-codes-21012"></a></td>
          <td>Gynecologic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21013<a name="example-referral-form-codes-21013"></a></td>
          <td>Head &amp; Neck</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21014<a name="example-referral-form-codes-21014"></a></td>
          <td>Hepatobiliary Pancreatic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21015<a name="example-referral-form-codes-21015"></a></td>
          <td>Luminal Upper and Lower Gastrointestinal</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21016<a name="example-referral-form-codes-21016"></a></td>
          <td>Cutaneous Skin / Soft Tissue</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21017<a name="example-referral-form-codes-21017"></a></td>
          <td>Suspicious imaging for malignancy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21018<a name="example-referral-form-codes-21018"></a></td>
          <td>Constitutional</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21019<a name="example-referral-form-codes-21019"></a></td>
          <td>Hematologic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21020<a name="example-referral-form-codes-21020"></a></td>
          <td>Unintentional, unexplained =10% weight loss (6�12 months, or shorter if severe)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21021<a name="example-referral-form-codes-21021"></a></td>
          <td>Persistent, unexplained fatigue, functionally impairing and not relieved by rest</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21022<a name="example-referral-form-codes-21022"></a></td>
          <td>Bone pain - long bone or spine</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21023<a name="example-referral-form-codes-21023"></a></td>
          <td>Persistent or unexplained abdominal pain</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21024<a name="example-referral-form-codes-21024"></a></td>
          <td>Persistent or unexplained pelvic pain</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21025<a name="example-referral-form-codes-21025"></a></td>
          <td>Subacute or progressive neurologic symptoms</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21026<a name="example-referral-form-codes-21026"></a></td>
          <td>Leukemia-pattern blood abnormalities</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21027<a name="example-referral-form-codes-21027"></a></td>
          <td>Lymphoma-pattern presentation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21028<a name="example-referral-form-codes-21028"></a></td>
          <td>MDS/MPN/Myeloma-pattern presentation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21029<a name="example-referral-form-codes-21029"></a></td>
          <td>Abnormal Imaging</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21036<a name="example-referral-form-codes-21036"></a></td>
          <td>Medical Issue Affecting Pregnancy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21037<a name="example-referral-form-codes-21037"></a></td>
          <td>Perioperative Assessment</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21039<a name="example-referral-form-codes-21039"></a></td>
          <td>Thyroid</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21040<a name="example-referral-form-codes-21040"></a></td>
          <td>Unexplained Weight Loss</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21041<a name="example-referral-form-codes-21041"></a></td>
          <td>Anemia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21042<a name="example-referral-form-codes-21042"></a></td>
          <td>Arrhythmia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21046<a name="example-referral-form-codes-21046"></a></td>
          <td>Preconception</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21047<a name="example-referral-form-codes-21047"></a></td>
          <td>Thrombocytopenia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21049<a name="example-referral-form-codes-21049"></a></td>
          <td>Venous Thromboembolism</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21050<a name="example-referral-form-codes-21050"></a></td>
          <td>Behavioural</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21051<a name="example-referral-form-codes-21051"></a></td>
          <td>Cardiac</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21052<a name="example-referral-form-codes-21052"></a></td>
          <td>Developmental / Growth</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21053<a name="example-referral-form-codes-21053"></a></td>
          <td>Dermatologic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21054<a name="example-referral-form-codes-21054"></a></td>
          <td>Endocrine</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21055<a name="example-referral-form-codes-21055"></a></td>
          <td>Gastrointestinal</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21056<a name="example-referral-form-codes-21056"></a></td>
          <td>Genetic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21058<a name="example-referral-form-codes-21058"></a></td>
          <td>Musculoskeletal / Rheumatologic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21059<a name="example-referral-form-codes-21059"></a></td>
          <td>Neonatal</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21060<a name="example-referral-form-codes-21060"></a></td>
          <td>Mental Health</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21061<a name="example-referral-form-codes-21061"></a></td>
          <td>Neurologic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21062<a name="example-referral-form-codes-21062"></a></td>
          <td>Renal</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21063<a name="example-referral-form-codes-21063"></a></td>
          <td>Respiratory</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21064<a name="example-referral-form-codes-21064"></a></td>
          <td>Attention Deficit Hyperactivity Disorder (ADHD)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21065<a name="example-referral-form-codes-21065"></a></td>
          <td>Autism Spectrum Disorder (ASD)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21067<a name="example-referral-form-codes-21067"></a></td>
          <td>Palpitations</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21069<a name="example-referral-form-codes-21069"></a></td>
          <td>Fine Motor Delay</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21070<a name="example-referral-form-codes-21070"></a></td>
          <td>Gross Motor Delay</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21071<a name="example-referral-form-codes-21071"></a></td>
          <td>Growth Concerns</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21072<a name="example-referral-form-codes-21072"></a></td>
          <td>Learning Disability / Learning Problem</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21073<a name="example-referral-form-codes-21073"></a></td>
          <td>Speech or Language Disorder</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21074<a name="example-referral-form-codes-21074"></a></td>
          <td>Failure to Thrive</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21075<a name="example-referral-form-codes-21075"></a></td>
          <td>Atopic Dermatitis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21076<a name="example-referral-form-codes-21076"></a></td>
          <td>Birth Mark</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21077<a name="example-referral-form-codes-21077"></a></td>
          <td>Hemangioma</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21078<a name="example-referral-form-codes-21078"></a></td>
          <td>Rash</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21080<a name="example-referral-form-codes-21080"></a></td>
          <td>Gender Dysphoria</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21081<a name="example-referral-form-codes-21081"></a></td>
          <td>Menstrual Irregularities</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21082<a name="example-referral-form-codes-21082"></a></td>
          <td>Obesity</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21083<a name="example-referral-form-codes-21083"></a></td>
          <td>Premature or Delayed Puberty</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21084<a name="example-referral-form-codes-21084"></a></td>
          <td>Short Stature</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21085<a name="example-referral-form-codes-21085"></a></td>
          <td>Thyroid Dysfunction</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21086<a name="example-referral-form-codes-21086"></a></td>
          <td>Abdominal Pain</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21089<a name="example-referral-form-codes-21089"></a></td>
          <td>Encopresis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21090<a name="example-referral-form-codes-21090"></a></td>
          <td>GERD</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21091<a name="example-referral-form-codes-21091"></a></td>
          <td>Dysmorphic / Syndromic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21092<a name="example-referral-form-codes-21092"></a></td>
          <td>Family History of Known Genetic Disorder</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21093<a name="example-referral-form-codes-21093"></a></td>
          <td>Trisomy 21</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21096<a name="example-referral-form-codes-21096"></a></td>
          <td>Neutropenia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21098<a name="example-referral-form-codes-21098"></a></td>
          <td>Gait Concerns</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21099<a name="example-referral-form-codes-21099"></a></td>
          <td>Joint / Bone Pain</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21100<a name="example-referral-form-codes-21100"></a></td>
          <td>Joint Swelling</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21101<a name="example-referral-form-codes-21101"></a></td>
          <td>Scoliosis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21102<a name="example-referral-form-codes-21102"></a></td>
          <td>Feeding Difficulties</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21103<a name="example-referral-form-codes-21103"></a></td>
          <td>Hyperbilirubinemia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21104<a name="example-referral-form-codes-21104"></a></td>
          <td>Low Birth Weight</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21105<a name="example-referral-form-codes-21105"></a></td>
          <td>Neonatal Seizures</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21106<a name="example-referral-form-codes-21106"></a></td>
          <td>Prematurity</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21107<a name="example-referral-form-codes-21107"></a></td>
          <td>Anxiety</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21108<a name="example-referral-form-codes-21108"></a></td>
          <td>Depression</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21109<a name="example-referral-form-codes-21109"></a></td>
          <td>Epilepsy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21110<a name="example-referral-form-codes-21110"></a></td>
          <td>Febrile Seizure(s)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21111<a name="example-referral-form-codes-21111"></a></td>
          <td>Headaches</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21112<a name="example-referral-form-codes-21112"></a></td>
          <td>Tics</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21113<a name="example-referral-form-codes-21113"></a></td>
          <td>Enuresis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21115<a name="example-referral-form-codes-21115"></a></td>
          <td>UTI(s)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21117<a name="example-referral-form-codes-21117"></a></td>
          <td>Persistent Cough</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21118<a name="example-referral-form-codes-21118"></a></td>
          <td>Upper and Lower Respiratory Issues</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21119<a name="example-referral-form-codes-21119"></a></td>
          <td>Abdominal Lesion / Mass</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21120<a name="example-referral-form-codes-21120"></a></td>
          <td>Abdominal Pain NYD - Chronic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21121<a name="example-referral-form-codes-21121"></a></td>
          <td>Anorectal / Perianal Conditions</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21122<a name="example-referral-form-codes-21122"></a></td>
          <td>Breast Conditions</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21123<a name="example-referral-form-codes-21123"></a></td>
          <td>Colonoscopy - Screening / Surveillance</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21124<a name="example-referral-form-codes-21124"></a></td>
          <td>Colorectal Conditions</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21126<a name="example-referral-form-codes-21126"></a></td>
          <td>Hepatobiliary &amp; Pancreatic Conditions</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21127<a name="example-referral-form-codes-21127"></a></td>
          <td>Hernias</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21128<a name="example-referral-form-codes-21128"></a></td>
          <td>Rectal Bleeding NYD</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21129<a name="example-referral-form-codes-21129"></a></td>
          <td>Skin &amp; Soft-Tissue Lesions</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21130<a name="example-referral-form-codes-21130"></a></td>
          <td>Upper GI Tract Disorder</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21131<a name="example-referral-form-codes-21131"></a></td>
          <td>Anal Region Disorders (e.g. fissures, fistulas, hemorrhoids)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21132<a name="example-referral-form-codes-21132"></a></td>
          <td>Fecal Incontinence</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21133<a name="example-referral-form-codes-21133"></a></td>
          <td>Pilonidal Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21134<a name="example-referral-form-codes-21134"></a></td>
          <td>Rectal Prolapse</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21135<a name="example-referral-form-codes-21135"></a></td>
          <td>Breast Lump</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21138<a name="example-referral-form-codes-21138"></a></td>
          <td>Screening</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21139<a name="example-referral-form-codes-21139"></a></td>
          <td>Surveillance</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21140<a name="example-referral-form-codes-21140"></a></td>
          <td>Colorectal Lesion / Mass (e.g. polyp, cancer)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21141<a name="example-referral-form-codes-21141"></a></td>
          <td>Diverticulitis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21142<a name="example-referral-form-codes-21142"></a></td>
          <td>Inflammatory Bowel Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21144<a name="example-referral-form-codes-21144"></a></td>
          <td>Parathyroid Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21145<a name="example-referral-form-codes-21145"></a></td>
          <td>Thyroid Mass / Enlargement</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21146<a name="example-referral-form-codes-21146"></a></td>
          <td>Gallbladder / Gallstone Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21147<a name="example-referral-form-codes-21147"></a></td>
          <td>Gallbladder Polyp / Mass</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21148<a name="example-referral-form-codes-21148"></a></td>
          <td>Liver Lesion / Mass</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21149<a name="example-referral-form-codes-21149"></a></td>
          <td>Pancreatic Lesion / Mass</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21150<a name="example-referral-form-codes-21150"></a></td>
          <td>Inguinal Hernia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21151<a name="example-referral-form-codes-21151"></a></td>
          <td>Umbilical / Epigastric Hernia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21152<a name="example-referral-form-codes-21152"></a></td>
          <td>Ventral / Incisional Hernia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21153<a name="example-referral-form-codes-21153"></a></td>
          <td>Benign Lesion (e.g. lipoma, cyst)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21154<a name="example-referral-form-codes-21154"></a></td>
          <td>Lymph Node</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21156<a name="example-referral-form-codes-21156"></a></td>
          <td>First-degree relative(s) with colorectal cancer</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21157<a name="example-referral-form-codes-21157"></a></td>
          <td>Hereditary cancer syndrome</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21158<a name="example-referral-form-codes-21158"></a></td>
          <td>First-degree relative(s) with documented advanced polyps before age 60</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21159<a name="example-referral-form-codes-21159"></a></td>
          <td>Frailty or Health / Social Complexity</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21160<a name="example-referral-form-codes-21160"></a></td>
          <td>Goals of Care and Future Planning</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21161<a name="example-referral-form-codes-21161"></a></td>
          <td>Medication Review / Advice</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21162<a name="example-referral-form-codes-21162"></a></td>
          <td>Mind or Mood</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21163<a name="example-referral-form-codes-21163"></a></td>
          <td>Mobility</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21164<a name="example-referral-form-codes-21164"></a></td>
          <td>Caregiver Burden</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21165<a name="example-referral-form-codes-21165"></a></td>
          <td>Complex Psychosocial / Economic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21166<a name="example-referral-form-codes-21166"></a></td>
          <td>Frailty</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21167<a name="example-referral-form-codes-21167"></a></td>
          <td>Generalized Functional Decline</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21168<a name="example-referral-form-codes-21168"></a></td>
          <td>Multi-morbidity</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21172<a name="example-referral-form-codes-21172"></a></td>
          <td>Cognitive Impairment</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21173<a name="example-referral-form-codes-21173"></a></td>
          <td>Mood Disorder</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21174<a name="example-referral-form-codes-21174"></a></td>
          <td>Responsive Behaviours (e.g. aggression, wandering etc...)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21175<a name="example-referral-form-codes-21175"></a></td>
          <td>Psychotic Symptoms (e.g. hallucinations, delusions, etc...)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21176<a name="example-referral-form-codes-21176"></a></td>
          <td>Impaired Gait / Balance</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21177<a name="example-referral-form-codes-21177"></a></td>
          <td>Falls</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21198<a name="example-referral-form-codes-21198"></a></td>
          <td>General Neurosurgery</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21199<a name="example-referral-form-codes-21199"></a></td>
          <td>Cranial / Brain &amp; Skull Lesions</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21201<a name="example-referral-form-codes-21201"></a></td>
          <td>Hydrocephalus / Cerebrospinal Fluid (CSF)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21202<a name="example-referral-form-codes-21202"></a></td>
          <td>Neurovascular</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21205<a name="example-referral-form-codes-21205"></a></td>
          <td>Cranial Arachnoid Cyst</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21206<a name="example-referral-form-codes-21206"></a></td>
          <td>Chiari Malformation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21207<a name="example-referral-form-codes-21207"></a></td>
          <td>Microvascular Decompression - Trigeminal Neuralgia, Hemifacial Spasm</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21208<a name="example-referral-form-codes-21208"></a></td>
          <td>Neurosurgery Spine (intradural pathology) - Syrinx, Arachnoid Cyst, Tumour, Tethered Cord, etc.</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21209<a name="example-referral-form-codes-21209"></a></td>
          <td>Subdural Hematoma - Chronic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21210<a name="example-referral-form-codes-21210"></a></td>
          <td>Brain Tumour - Primary</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21211<a name="example-referral-form-codes-21211"></a></td>
          <td>Brain Tumour - Metastatic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21212<a name="example-referral-form-codes-21212"></a></td>
          <td>Meningioma</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21213<a name="example-referral-form-codes-21213"></a></td>
          <td>Pituitary / Sellar Lesion</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21214<a name="example-referral-form-codes-21214"></a></td>
          <td>Skull Base / Cranial Nerve Tumour</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21215<a name="example-referral-form-codes-21215"></a></td>
          <td>Epilepsy Surgery Assessment</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21216<a name="example-referral-form-codes-21216"></a></td>
          <td>Neuromodulation for Pain</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21217<a name="example-referral-form-codes-21217"></a></td>
          <td>Parkinson's - Deep Brain Stimulation Surgical Assessment</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21218<a name="example-referral-form-codes-21218"></a></td>
          <td>Other Movement Disorder - Deep Brain Stimulation Surgical Assessment</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21219<a name="example-referral-form-codes-21219"></a></td>
          <td>CSF Shunt Assessment (Insertion / Revision / Removal)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21220<a name="example-referral-form-codes-21220"></a></td>
          <td>Hydrocephalus - Normal Pressure (NPH)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21221<a name="example-referral-form-codes-21221"></a></td>
          <td>Hydrocephalus - Other (non-NPH)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21222<a name="example-referral-form-codes-21222"></a></td>
          <td>Arteriovenous Malformation (AVM) / Dural AV Fistula</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21223<a name="example-referral-form-codes-21223"></a></td>
          <td>Brain Aneurysm - Unruptured</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21224<a name="example-referral-form-codes-21224"></a></td>
          <td>Carotid Stenosis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21225<a name="example-referral-form-codes-21225"></a></td>
          <td>Cavernous Malformation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21226<a name="example-referral-form-codes-21226"></a></td>
          <td>Brachial Plexus Injury/Lesion</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21229<a name="example-referral-form-codes-21229"></a></td>
          <td>Ulnar Nerve Entrapment</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21230<a name="example-referral-form-codes-21230"></a></td>
          <td>Other Focal Nerve Entrapment (radial, peroneal, etc.)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21231<a name="example-referral-form-codes-21231"></a></td>
          <td>Cervical</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21232<a name="example-referral-form-codes-21232"></a></td>
          <td>Thoracic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21233<a name="example-referral-form-codes-21233"></a></td>
          <td>Lumbar</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21234<a name="example-referral-form-codes-21234"></a></td>
          <td>Congenital Hemolytic Anemia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21236<a name="example-referral-form-codes-21236"></a></td>
          <td>Hereditary Spherocytosis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21238<a name="example-referral-form-codes-21238"></a></td>
          <td>Thalassemia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21239<a name="example-referral-form-codes-21239"></a></td>
          <td>Uncomplicated Hemoglobinopathy Trait (Sickle Trait, Thalassemia Trait)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21240<a name="example-referral-form-codes-21240"></a></td>
          <td>Aneurysm / Dissection - Asymptomatic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21241<a name="example-referral-form-codes-21241"></a></td>
          <td>Carotid Stenosis - Asymptomatic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21242<a name="example-referral-form-codes-21242"></a></td>
          <td>Diabetic Foot Ulcers</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21243<a name="example-referral-form-codes-21243"></a></td>
          <td>Peripheral Arterial Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21244<a name="example-referral-form-codes-21244"></a></td>
          <td>Venous Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21245<a name="example-referral-form-codes-21245"></a></td>
          <td>Abdominal Aortic Aneurysm (AAA)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21246<a name="example-referral-form-codes-21246"></a></td>
          <td>Descending Thoracic Aortic Aneurysm, Pathology or Dissection</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21247<a name="example-referral-form-codes-21247"></a></td>
          <td>Other Aneurysm (e.g. Popliteal, Visceral, Renal)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21248<a name="example-referral-form-codes-21248"></a></td>
          <td>With high risk features (e.g. ulcerated / irregular plaque, plaque hemorrhage, contralateral ICA occlusion, progressive stenosis, young patients)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21249<a name="example-referral-form-codes-21249"></a></td>
          <td>Symptoms within 2 weeks to 6 months and more than 50% ICA stenosis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21250<a name="example-referral-form-codes-21250"></a></td>
          <td>Without high risk features, more than 50% ICA stenosis and no symptoms within 6 months</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21251<a name="example-referral-form-codes-21251"></a></td>
          <td>Ulcer</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21252<a name="example-referral-form-codes-21252"></a></td>
          <td>Active infection</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21254<a name="example-referral-form-codes-21254"></a></td>
          <td>Asymptomatic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21255<a name="example-referral-form-codes-21255"></a></td>
          <td>Claudication</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21256<a name="example-referral-form-codes-21256"></a></td>
          <td>Chronic Limb-Threatening Ischemia (e.g. rest pain, tissue loss)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21257<a name="example-referral-form-codes-21257"></a></td>
          <td>Upper Extremity Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21258<a name="example-referral-form-codes-21258"></a></td>
          <td>Varicose Veins with complication</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21259<a name="example-referral-form-codes-21259"></a></td>
          <td>Varicose Veins without complication</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21260<a name="example-referral-form-codes-21260"></a></td>
          <td>Upper Extremity Venous Disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21261<a name="example-referral-form-codes-21261"></a></td>
          <td>Currently Pregnant</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21262<a name="example-referral-form-codes-21262"></a></td>
          <td>Currently Pregnant or &lt;12 Months Postpartum</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21264<a name="example-referral-form-codes-21264"></a></td>
          <td>Second Opinion</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21265<a name="example-referral-form-codes-21265"></a></td>
          <td>Recent Hospitalization or ER Visit for this issue</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21266<a name="example-referral-form-codes-21266"></a></td>
          <td>&lt; 1 Year Old</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21267<a name="example-referral-form-codes-21267"></a></td>
          <td>Referral for child or youth (&lt;18 years old)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21268<a name="example-referral-form-codes-21268"></a></td>
          <td>Preoperative Management</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21269<a name="example-referral-form-codes-21269"></a></td>
          <td>Cognitively impaired</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21270<a name="example-referral-form-codes-21270"></a></td>
          <td>Falls risk</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21271<a name="example-referral-form-codes-21271"></a></td>
          <td>Hearing impaired</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21272<a name="example-referral-form-codes-21272"></a></td>
          <td>Patient requires lift</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21273<a name="example-referral-form-codes-21273"></a></td>
          <td>Vision impaired</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21274<a name="example-referral-form-codes-21274"></a></td>
          <td>Wheelchair</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21275<a name="example-referral-form-codes-21275"></a></td>
          <td>Allied Health Professional</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21276<a name="example-referral-form-codes-21276"></a></td>
          <td>Family Physician</td>
          <td>Médecin de famille</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">21277<a name="example-referral-form-codes-21277"></a></td>
          <td>Physician Assistant</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21278<a name="example-referral-form-codes-21278"></a></td>
          <td>Medical Student</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21279<a name="example-referral-form-codes-21279"></a></td>
          <td>Nurse</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21280<a name="example-referral-form-codes-21280"></a></td>
          <td>Nurse Practitioner</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21281<a name="example-referral-form-codes-21281"></a></td>
          <td>Resident</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21282<a name="example-referral-form-codes-21282"></a></td>
          <td>Specialist</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21283<a name="example-referral-form-codes-21283"></a></td>
          <td>No known kidney issues</td>
          <td>Aucun problème rénal connu</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">21284<a name="example-referral-form-codes-21284"></a></td>
          <td>Yes, patient has impaired renal function or a history of renal transplant</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21285<a name="example-referral-form-codes-21285"></a></td>
          <td>eGFR result</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21286<a name="example-referral-form-codes-21286"></a></td>
          <td>Has diabetes</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21287<a name="example-referral-form-codes-21287"></a></td>
          <td>On dialysis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21288<a name="example-referral-form-codes-21288"></a></td>
          <td>Known hypersensitivity to contrast agents</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21289<a name="example-referral-form-codes-21289"></a></td>
          <td>History of reaction before the year 2000</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21291<a name="example-referral-form-codes-21291"></a></td>
          <td>Estimated Date of Delivery</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21292<a name="example-referral-form-codes-21292"></a></td>
          <td>Last Menstrual Period</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21293<a name="example-referral-form-codes-21293"></a></td>
          <td>Currently breastfeeding</td>
          <td>Allaite actuellement</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">21294<a name="example-referral-form-codes-21294"></a></td>
          <td>Claustrophobia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21295<a name="example-referral-form-codes-21295"></a></td>
          <td>Require general anesthesia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21296<a name="example-referral-form-codes-21296"></a></td>
          <td>Has metal fragments in eye(s)/body</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21297<a name="example-referral-form-codes-21297"></a></td>
          <td>Has active electronic implants (e.g. Cardiac Implantable Electronic Device, Neurostimulator, Cochlear Implant, Medication Pump, etc.) or retained parts (e.g. leads, etc.):</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21298<a name="example-referral-form-codes-21298"></a></td>
          <td>Has other metal containing devices (e.g. Aneurysm Clip, IUD, Tissue Expander, Shunt, Stent, Coil, Traction Device, Glucose Monitor, etc.), metal foreign bodies (Shrapnel, Bullets, Subdermal Piercings, Etc), or orthopedic device:</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21299<a name="example-referral-form-codes-21299"></a></td>
          <td>CIED</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21300<a name="example-referral-form-codes-21300"></a></td>
          <td>Neurostimulator</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21301<a name="example-referral-form-codes-21301"></a></td>
          <td>Cochlear Implant</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21302<a name="example-referral-form-codes-21302"></a></td>
          <td>Medication Pump</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21303<a name="example-referral-form-codes-21303"></a></td>
          <td>Aneurysm Clip</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21304<a name="example-referral-form-codes-21304"></a></td>
          <td>Coil</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21305<a name="example-referral-form-codes-21305"></a></td>
          <td>Glucose Monitor</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21306<a name="example-referral-form-codes-21306"></a></td>
          <td>Heart Valve</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21307<a name="example-referral-form-codes-21307"></a></td>
          <td>Copper or Stainless Steel IUD</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21308<a name="example-referral-form-codes-21308"></a></td>
          <td>Orthopedic Devices</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21309<a name="example-referral-form-codes-21309"></a></td>
          <td>Pessary</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21310<a name="example-referral-form-codes-21310"></a></td>
          <td>Prosthesis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21311<a name="example-referral-form-codes-21311"></a></td>
          <td>Shunt</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21312<a name="example-referral-form-codes-21312"></a></td>
          <td>Stent</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21313<a name="example-referral-form-codes-21313"></a></td>
          <td>Subdermal Piercings</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21314<a name="example-referral-form-codes-21314"></a></td>
          <td>Tissue Expander</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21315<a name="example-referral-form-codes-21315"></a></td>
          <td>Traction Device</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21316<a name="example-referral-form-codes-21316"></a></td>
          <td>Patient has impaired renal function or a history of renal transplant</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21317<a name="example-referral-form-codes-21317"></a></td>
          <td>She/Her</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21318<a name="example-referral-form-codes-21318"></a></td>
          <td>He/Him</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21319<a name="example-referral-form-codes-21319"></a></td>
          <td>They/Them</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21320<a name="example-referral-form-codes-21320"></a></td>
          <td>Immunocompromised</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21321<a name="example-referral-form-codes-21321"></a></td>
          <td>Left</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21322<a name="example-referral-form-codes-21322"></a></td>
          <td>Right</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21323<a name="example-referral-form-codes-21323"></a></td>
          <td>Bilateral</td>
          <td>Bilatéral</td>
        </tr>
        <tr>
          <td style="white-space:nowrap">21324<a name="example-referral-form-codes-21324"></a></td>
          <td>Patient cannot provide reliable medical history or provide consent to contrast injections (where applicable)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21325<a name="example-referral-form-codes-21325"></a></td>
          <td>Abnormal Lab Finding</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21326<a name="example-referral-form-codes-21326"></a></td>
          <td>Vomiting</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21327<a name="example-referral-form-codes-21327"></a></td>
          <td>Weight Loss</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21328<a name="example-referral-form-codes-21328"></a></td>
          <td>Eating Concerns</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21329<a name="example-referral-form-codes-21329"></a></td>
          <td>Custody Considerations</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21330<a name="example-referral-form-codes-21330"></a></td>
          <td>Child Welfare Agency Involvement (e.g., Children's Aid Society)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21331<a name="example-referral-form-codes-21331"></a></td>
          <td>Suspected Malignancy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21332<a name="example-referral-form-codes-21332"></a></td>
          <td>Confirmed Malignancy</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21333<a name="example-referral-form-codes-21333"></a></td>
          <td>Endocrine Conditions</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21344<a name="example-referral-form-codes-21344"></a></td>
          <td>Breast Inflammation / Abscess</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21345<a name="example-referral-form-codes-21345"></a></td>
          <td>Imaging Abnormality</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21346<a name="example-referral-form-codes-21346"></a></td>
          <td>Wound Management</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21347<a name="example-referral-form-codes-21347"></a></td>
          <td>G6PD Deficiency</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21348<a name="example-referral-form-codes-21348"></a></td>
          <td>PK Deficiency</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21349<a name="example-referral-form-codes-21349"></a></td>
          <td>HbSS</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21350<a name="example-referral-form-codes-21350"></a></td>
          <td>HbSC</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21351<a name="example-referral-form-codes-21351"></a></td>
          <td>HbS/�-thalassemia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21352<a name="example-referral-form-codes-21352"></a></td>
          <td>Transfusion-Dependent Thalassemia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21353<a name="example-referral-form-codes-21353"></a></td>
          <td>Non-Transfusion-Dependent Thalassemia</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21354<a name="example-referral-form-codes-21354"></a></td>
          <td>Movement Disorder</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21355<a name="example-referral-form-codes-21355"></a></td>
          <td>Unintentional Weight Change / Nutritional Concerns</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21356<a name="example-referral-form-codes-21356"></a></td>
          <td>Sleep Concerns</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21357<a name="example-referral-form-codes-21357"></a></td>
          <td>Arrived in Canada in past 3-6 months</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21358<a name="example-referral-form-codes-21358"></a></td>
          <td>Recent or Ongoing Complications</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21359<a name="example-referral-form-codes-21359"></a></td>
          <td>Referred from Sickle Cell Comprehensive Care Clinic</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21360<a name="example-referral-form-codes-21360"></a></td>
          <td>Requires ongoing Red Blood Cell transfusion support</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21361<a name="example-referral-form-codes-21361"></a></td>
          <td>Transfer of care</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21362<a name="example-referral-form-codes-21362"></a></td>
          <td>Non-Invasive Vascular Testing</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21363<a name="example-referral-form-codes-21363"></a></td>
          <td>Vascular Consultation</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21364<a name="example-referral-form-codes-21364"></a></td>
          <td>Nerve Root Impingement / Radiculopathy Present</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21365<a name="example-referral-form-codes-21365"></a></td>
          <td>Functional Neurosurgery - Surgical Assessment (Epilepsy, Movement, Pain)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21366<a name="example-referral-form-codes-21366"></a></td>
          <td>Adrenals</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21367<a name="example-referral-form-codes-21367"></a></td>
          <td>Bone</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21368<a name="example-referral-form-codes-21368"></a></td>
          <td>Kidneys</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21369<a name="example-referral-form-codes-21369"></a></td>
          <td>Liver</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21370<a name="example-referral-form-codes-21370"></a></td>
          <td>Lung</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21371<a name="example-referral-form-codes-21371"></a></td>
          <td>Lymph nodes</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21372<a name="example-referral-form-codes-21372"></a></td>
          <td>Mediastinal mass</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21373<a name="example-referral-form-codes-21373"></a></td>
          <td>Pancreas</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21374<a name="example-referral-form-codes-21374"></a></td>
          <td>Pelvis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21375<a name="example-referral-form-codes-21375"></a></td>
          <td>Thoracic Outlet Syndrome</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21376<a name="example-referral-form-codes-21376"></a></td>
          <td>Arterial</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21377<a name="example-referral-form-codes-21377"></a></td>
          <td>Venous</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21378<a name="example-referral-form-codes-21378"></a></td>
          <td>Arm</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21379<a name="example-referral-form-codes-21379"></a></td>
          <td>Leg</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21380<a name="example-referral-form-codes-21380"></a></td>
          <td>Ankle brachial index (screening)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21381<a name="example-referral-form-codes-21381"></a></td>
          <td>Fasting</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21382<a name="example-referral-form-codes-21382"></a></td>
          <td>Post-prandial</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21383<a name="example-referral-form-codes-21383"></a></td>
          <td>Existing PICC line</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21384<a name="example-referral-form-codes-21384"></a></td>
          <td>Existing Port-a-Cath</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21385<a name="example-referral-form-codes-21385"></a></td>
          <td>What is the patient's current resting heart rate (bpm)?</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21386<a name="example-referral-form-codes-21386"></a></td>
          <td>Known contraindications to Nitroglycerin:</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21387<a name="example-referral-form-codes-21387"></a></td>
          <td>Is the patient currently on beta-blockers?</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21388<a name="example-referral-form-codes-21388"></a></td>
          <td>Severe/critical aortic stenosis</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21389<a name="example-referral-form-codes-21389"></a></td>
          <td>Severe symptomatic aortic insufficiency</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21390<a name="example-referral-form-codes-21390"></a></td>
          <td>Decompensated congestive heart failure</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21391<a name="example-referral-form-codes-21391"></a></td>
          <td>Allergy to Beta-blockers</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21392<a name="example-referral-form-codes-21392"></a></td>
          <td>Prior hospitalization for lung disease</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21393<a name="example-referral-form-codes-21393"></a></td>
          <td>Active bronchospasm</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21394<a name="example-referral-form-codes-21394"></a></td>
          <td>2nd or 3rd degree heart block, or 1st degree with PR&gt;0.42s</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21395<a name="example-referral-form-codes-21395"></a></td>
          <td>Will the patient be prescribed a beta-blocker?</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21396<a name="example-referral-form-codes-21396"></a></td>
          <td>Spinal Cord Compression Present</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21397<a name="example-referral-form-codes-21397"></a></td>
          <td>Date of First Suspicion of Cancer</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21398<a name="example-referral-form-codes-21398"></a></td>
          <td>Abdomen Pelvis Angiography</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21399<a name="example-referral-form-codes-21399"></a></td>
          <td>None of the above</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21400<a name="example-referral-form-codes-21400"></a></td>
          <td>Unsure/Unknown</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21401<a name="example-referral-form-codes-21401"></a></td>
          <td>Intersex</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21402<a name="example-referral-form-codes-21402"></a></td>
          <td>Other</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21403<a name="example-referral-form-codes-21403"></a></td>
          <td>Translator Required</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21404<a name="example-referral-form-codes-21404"></a></td>
          <td>Preferred Name</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21405<a name="example-referral-form-codes-21405"></a></td>
          <td>Voicemails acceptable</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21406<a name="example-referral-form-codes-21406"></a></td>
          <td>Alternate contact</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21407<a name="example-referral-form-codes-21407"></a></td>
          <td>Yes</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21408<a name="example-referral-form-codes-21408"></a></td>
          <td>No</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21409<a name="example-referral-form-codes-21409"></a></td>
          <td>Unsafe contact persons (do not speak with)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21410<a name="example-referral-form-codes-21410"></a></td>
          <td>Only speak with patient directly</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21411<a name="example-referral-form-codes-21411"></a></td>
          <td>Accessibility concerns or disability</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21412<a name="example-referral-form-codes-21412"></a></td>
          <td>Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21413<a name="example-referral-form-codes-21413"></a></td>
          <td>Send copies of reports to additional providers</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21414<a name="example-referral-form-codes-21414"></a></td>
          <td>This is the Primary Care Provider</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21415<a name="example-referral-form-codes-21415"></a></td>
          <td>CPP attached separately (if not entered below)</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21416<a name="example-referral-form-codes-21416"></a></td>
          <td>Preferred consultant or location</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21417<a name="example-referral-form-codes-21417"></a></td>
          <td>Patient willing to travel for shorter wait time</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21418<a name="example-referral-form-codes-21418"></a></td>
          <td>Personal Health Information that is medically relevant has not been disclosed at the request of the patient.</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21419<a name="example-referral-form-codes-21419"></a></td>
          <td>OHIP</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21420<a name="example-referral-form-codes-21420"></a></td>
          <td>WSIB Case</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21421<a name="example-referral-form-codes-21421"></a></td>
          <td>DND</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21422<a name="example-referral-form-codes-21422"></a></td>
          <td>IFH</td>
          <td />
        </tr>
        <tr>
          <td style="white-space:nowrap">21423<a name="example-referral-form-codes-21423"></a></td>
          <td>RAMQ</td>
          <td />
        </tr>
      </table>
    </div>
  </text>
  <url value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
  <version value="1.2.0" />
  <name value="ExampleReferralFormCodes" />
  <title value="Example Referral Form Codes" />
  <status value="active" />
  <experimental value="true" />
  <publisher value="Ontario Health" />
  <description value="An example set of Ontario Health custom codes identifying standardized referral form (SRF) terms and/or concepts.  Not for use with 'real' forms." />
  <jurisdiction>
    <coding>
      <system value="urn:iso:std:iso:3166" />
      <code value="CA" />
    </coding>
  </jurisdiction>
  <caseSensitive value="true" />
  <content value="complete" />
  <count value="1288" />
  <concept>
    <code value="20001" />
    <display value="Cardiac Testing" />
  </concept>
  <concept>
    <code value="20002" />
    <display value="Cardiology Consultation" />
  </concept>
  <concept>
    <code value="20003" />
    <display value="24 Hour Ambulatory Blood Pressure Monitoring (Not OHIP Covered)" />
  </concept>
  <concept>
    <code value="20004" />
    <display value="Coronary Angiogram" />
  </concept>
  <concept>
    <code value="20005" />
    <display value="Echocardiogram - Resting" />
  </concept>
  <concept>
    <code value="20006" />
    <display value="Electrocardiogram (ECG)" />
  </concept>
  <concept>
    <code value="20007" />
    <display value="Holter Monitoring" />
  </concept>
  <concept>
    <code value="20008" />
    <display value="Loop / Event Monitor" />
  </concept>
  <concept>
    <code value="20009" />
    <display value="Stress Testing" />
  </concept>
  <concept>
    <code value="20010" />
    <display value="Nuclear Medicine" />
  </concept>
  <concept>
    <code value="20011" />
    <display value="Tilt Table Testing" />
  </concept>
  <concept>
    <code value="20012" />
    <display value="Echocardiogram (2D)" />
  </concept>
  <concept>
    <code value="20013" />
    <display value="Echocardiogram with Contrast" />
  </concept>
  <concept>
    <code value="20014" />
    <display value="Echocardiogram with Saline (Bubble)" />
  </concept>
  <concept>
    <code value="20015" />
    <display value="Pediatric Echocardiogram" />
  </concept>
  <concept>
    <code value="20016" />
    <display value="Transesophageal Echocardiogram (TEE)" />
  </concept>
  <concept>
    <code value="20017" />
    <display value="24 Hours" />
  </concept>
  <concept>
    <code value="20018" />
    <display value="48 Hours" />
  </concept>
  <concept>
    <code value="20019" />
    <display value="72 Hours" />
  </concept>
  <concept>
    <code value="20020" />
    <display value="7 Days" />
  </concept>
  <concept>
    <code value="20021" />
    <display value="14 Days" />
  </concept>
  <concept>
    <code value="20022" />
    <display value="ECG - Exercise Stress Test" />
  </concept>
  <concept>
    <code value="20023" />
    <display value="ECG - Dobutamine/Persantine Stress Test" />
  </concept>
  <concept>
    <code value="20024" />
    <display value="Echocardiogram - Exercise Stress Test" />
  </concept>
  <concept>
    <code value="20025" />
    <display value="Echocardiogram - Dobutamine/Persantine Stress Test" />
  </concept>
  <concept>
    <code value="20026" />
    <display value="MUGA - Resting" />
  </concept>
  <concept>
    <code value="20027" />
    <display value="Cardiac Pyrophosphate" />
  </concept>
  <concept>
    <code value="20028" />
    <display value="MIBI Scans / Myocardial Perfusion Imaging (MPI):" />
  </concept>
  <concept>
    <code value="20029" />
    <display value="MIBI Scan - Exercise Stress Test" />
  </concept>
  <concept>
    <code value="20030" />
    <display value="MIBI Scan - Dobutamine/Persantine Stress Test" />
  </concept>
  <concept>
    <code value="20031" />
    <display value="Thallium Viability Test" />
  </concept>
  <concept>
    <code value="20032" />
    <display value="Arrythmias or Palpitations" />
  </concept>
  <concept>
    <code value="20033" />
    <display value="Cardiovascular Risk Assessment" />
  </concept>
  <concept>
    <code value="20034" />
    <display value="Chest Pain or Angina" />
  </concept>
  <concept>
    <code value="20035" />
    <display value="Congenital Heart Disease" />
  </concept>
  <concept>
    <code value="20036" />
    <display value="Congestive Heart Failure" />
  </concept>
  <concept>
    <code value="20037" />
    <display value="Coronary Artery Disease" />
  </concept>
  <concept>
    <code value="20038" />
    <display value="Dyspnea" />
  </concept>
  <concept>
    <code value="20039" />
    <display value="Hypertension" />
  </concept>
  <concept>
    <code value="20040" />
    <display value="Murmur" />
  </concept>
  <concept>
    <code value="20041" />
    <display value="Pericardial Disease" />
  </concept>
  <concept>
    <code value="20042" />
    <display value="Peripheral Edema" />
  </concept>
  <concept>
    <code value="20043" />
    <display value="Post-Myocardial Infarction" />
  </concept>
  <concept>
    <code value="20044" />
    <display value="Pre-Operative Consultation" />
  </concept>
  <concept>
    <code value="20045" />
    <display value="Syncope" />
  </concept>
  <concept>
    <code value="20046" />
    <display value="Valvular Heart Disease or Prosthetic Heart Valve" />
  </concept>
  <concept>
    <code value="20047" />
    <display value="Acne or Rosacea" />
  </concept>
  <concept>
    <code value="20048" />
    <display value="Alopecia or Hair Loss" />
  </concept>
  <concept>
    <code value="20049" />
    <display value="Cosmetic" />
  </concept>
  <concept>
    <code value="20050" />
    <display value="Eczema or Dermatitis" />
  </concept>
  <concept>
    <code value="20051" />
    <display value="Hidradenitis Suppurativa" />
  </concept>
  <concept>
    <code value="20052" />
    <display value="Hives or Urticaria" />
  </concept>
  <concept>
    <code value="20053" />
    <display value="Nail Concerns" />
  </concept>
  <concept>
    <code value="20054" />
    <display value="Pruritus NYD" />
  </concept>
  <concept>
    <code value="20055" />
    <display value="Psoriasis" />
  </concept>
  <concept>
    <code value="20056" />
    <display value="Rash NYD" />
  </concept>
  <concept>
    <code value="20057" />
    <display value="Skin Cancer or Suspicious Lesion(s)" />
  </concept>
  <concept>
    <code value="20058" />
    <display value="Skin Check" />
  </concept>
  <concept>
    <code value="20059" />
    <display value="Skin Infection - Chronic" />
  </concept>
  <concept>
    <code value="20060" />
    <display value="Ulcer or Wounds" />
  </concept>
  <concept>
    <code value="20061" />
    <display value="Warts" />
  </concept>
  <concept>
    <code value="20062" />
    <display value="Vitiligo" />
  </concept>
  <concept>
    <code value="20063" />
    <display value="Actinic Keratoses" />
  </concept>
  <concept>
    <code value="20064" />
    <display value="Basal Cell Cancer" />
  </concept>
  <concept>
    <code value="20065" />
    <display value="Squamous Cell Cancer" />
  </concept>
  <concept>
    <code value="20066" />
    <display value="Melanoma" />
  </concept>
  <concept>
    <code value="20067" />
    <display value="Suspicious Lesion(s)" />
  </concept>
  <concept>
    <code value="20068" />
    <display value="Biopsy confirmed" />
  </concept>
  <concept>
    <code value="20069" />
    <display value="Abdominal Pain NYD or Bloating" />
  </concept>
  <concept>
    <code value="20070" />
    <display value="Barrett's Esophagus - Surveillance" />
  </concept>
  <concept>
    <code value="20071" />
    <display value="Bleeding" />
  </concept>
  <concept>
    <code value="20072" />
    <display value="Colonoscopy Request (Abnormal FIT, Screening, Surveillance)" />
  </concept>
  <concept>
    <code value="20073" />
    <display value="Bowel Changes (Constipation, Diarrhea)" />
  </concept>
  <concept>
    <code value="20074" />
    <display value="Dysphagia" />
  </concept>
  <concept>
    <code value="20075" />
    <display value="Gastroesophageal Reflux Disease (GERD)" />
  </concept>
  <concept>
    <code value="20076" />
    <display value="Irritable Bowel Syndrome" />
  </concept>
  <concept>
    <code value="20077" />
    <display value="Inflammatory Bowel Disease (IBD)" />
  </concept>
  <concept>
    <code value="20078" />
    <display value="Iron Deficiency Anemia - Unexplained" />
  </concept>
  <concept>
    <code value="20079" />
    <display value="Liver Disease" />
  </concept>
  <concept>
    <code value="20080" />
    <display value="Nausea or Vomiting NYD" />
  </concept>
  <concept>
    <code value="20081" />
    <display value="Pancreatic Disease" />
  </concept>
  <concept>
    <code value="20082" />
    <display value="Weight Loss - Unexplained" />
  </concept>
  <concept>
    <code value="20083" />
    <display value="Lower GI or Rectal" />
  </concept>
  <concept>
    <code value="20084" />
    <display value="Upper GI" />
  </concept>
  <concept>
    <code value="20085" />
    <display value="Constipation" />
  </concept>
  <concept>
    <code value="20086" />
    <display value="Diarrhea" />
  </concept>
  <concept>
    <code value="20087" />
    <display value="Abnormal FIT" />
  </concept>
  <concept>
    <code value="20088" />
    <display value="Average Risk" />
  </concept>
  <concept>
    <code value="20089" />
    <display value="First-Degree Relative with Colorectal Cancer" />
  </concept>
  <concept>
    <code value="20090" />
    <display value="Other Family History" />
  </concept>
  <concept>
    <code value="20091" />
    <display value="Prior History of Colorectal Polyps" />
  </concept>
  <concept>
    <code value="20092" />
    <display value="Prior History of Colorectal Cancer" />
  </concept>
  <concept>
    <code value="20093" />
    <display value="Surveillance in IBD Colitis of at least 8 years duration" />
  </concept>
  <concept>
    <code value="20094" />
    <display value="Crohn's disease" />
  </concept>
  <concept>
    <code value="20095" />
    <display value="Ulcerative colitis" />
  </concept>
  <concept>
    <code value="20096" />
    <display value="Alcohol Associated Liver Disease" />
  </concept>
  <concept>
    <code value="20097" />
    <display value="Cirrhosis" />
  </concept>
  <concept>
    <code value="20098" />
    <display value="Hepatitis B" />
  </concept>
  <concept>
    <code value="20099" />
    <display value="Hepatitis C" />
  </concept>
  <concept>
    <code value="20100" />
    <display value="Liver Function Tests - Abnormal" />
  </concept>
  <concept>
    <code value="20101" />
    <display value="Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) / Fatty Liver" />
  </concept>
  <concept>
    <code value="20102" />
    <display value="Abnormal Imaging of Pancreas" />
  </concept>
  <concept>
    <code value="20103" />
    <display value="Pancreatitis" />
  </concept>
  <concept>
    <code value="20104" />
    <display value="Ear and Hearing" />
  </concept>
  <concept>
    <code value="20105" />
    <display value="Facial Plastics &amp; Reconstruction" />
  </concept>
  <concept>
    <code value="20106" />
    <display value="Head, Neck and Thyroid (Malignancy, Masses, Nodules, or Cysts)" />
  </concept>
  <concept>
    <code value="20107" />
    <display value="Nose and Sinus" />
  </concept>
  <concept>
    <code value="20108" />
    <display value="Throat and Oral Cavity" />
  </concept>
  <concept>
    <code value="20109" />
    <display value="Cerumen Impaction" />
  </concept>
  <concept>
    <code value="20110" />
    <display value="Eustachian Tube Dysfunction" />
  </concept>
  <concept>
    <code value="20111" />
    <display value="Hearing Loss - Sudden / Unilateral" />
  </concept>
  <concept>
    <code value="20112" />
    <display value="Otitis Externa" />
  </concept>
  <concept>
    <code value="20113" />
    <display value="Otitis Media" />
  </concept>
  <concept>
    <code value="20114" />
    <display value="Tinnitus" />
  </concept>
  <concept>
    <code value="20115" />
    <display value="Vertigo or Dizziness" />
  </concept>
  <concept>
    <code value="20116" />
    <display value="Nasopharyngeal Lesions" />
  </concept>
  <concept>
    <code value="20117" />
    <display value="Oropharyngeal Lesions" />
  </concept>
  <concept>
    <code value="20118" />
    <display value="Parathyroid Cyst, Nodule, or Mass" />
  </concept>
  <concept>
    <code value="20119" />
    <display value="Salivary Gland Mass" />
  </concept>
  <concept>
    <code value="20120" />
    <display value="Skin Cancer" />
  </concept>
  <concept>
    <code value="20121" />
    <display value="Thyroid Cyst, Nodule, or Mass" />
  </concept>
  <concept>
    <code value="20122" />
    <display value="Anosmia or Hyposmia" />
  </concept>
  <concept>
    <code value="20123" />
    <display value="Deviated Nasal Septum" />
  </concept>
  <concept>
    <code value="20124" />
    <display value="Epistaxis" />
  </concept>
  <concept>
    <code value="20125" />
    <display value="Foreign Body Removal" />
  </concept>
  <concept>
    <code value="20126" />
    <display value="Nasal Polyps" />
  </concept>
  <concept>
    <code value="20127" />
    <display value="Rhinitis or Sinusitis - Chronic" />
  </concept>
  <concept>
    <code value="20128" />
    <display value="Cough or Throat Clearing - Chronic" />
  </concept>
  <concept>
    <code value="20130" />
    <display value="Dysphonia / Hoarse voice" />
  </concept>
  <concept>
    <code value="20131" />
    <display value="Globus Sensation" />
  </concept>
  <concept>
    <code value="20132" />
    <display value="Lymphadenopathy" />
  </concept>
  <concept>
    <code value="20133" />
    <display value="Odynophagia" />
  </concept>
  <concept>
    <code value="20134" />
    <display value="Salivary Gland Stones" />
  </concept>
  <concept>
    <code value="20135" />
    <display value="Sleep-Related Breathing Disorders (e.g. OSA)" />
  </concept>
  <concept>
    <code value="20136" />
    <display value="Speech and Language Delay" />
  </concept>
  <concept>
    <code value="20137" />
    <display value="Tongue Tie" />
  </concept>
  <concept>
    <code value="20138" />
    <display value="Tonsillar or Adenoid Disorders" />
  </concept>
  <concept>
    <code value="20139" />
    <display value="Respiratory Testing" />
  </concept>
  <concept>
    <code value="20140" />
    <display value="Respirology Consultation" />
  </concept>
  <concept>
    <code value="20141" />
    <display value="Spirometry (Include post-bronchodilator, if indicated)" />
  </concept>
  <concept>
    <code value="20142" />
    <display value="Full Pulmonary Function Testing (Include post-bronchodilator, if indicated)" />
  </concept>
  <concept>
    <code value="20143" />
    <display value="Asthma" />
  </concept>
  <concept>
    <code value="20144" />
    <display value="Cough NYD" />
  </concept>
  <concept>
    <code value="20145" />
    <display value="Chronic Obstructive Pulmonary Disease (COPD)" />
  </concept>
  <concept>
    <code value="20146" />
    <display value="Dyspnea NYD" />
  </concept>
  <concept>
    <code value="20147" />
    <display value="Interstitial Lung Disease" />
  </concept>
  <concept>
    <code value="20148" />
    <display value="Adrenal Mass" />
  </concept>
  <concept>
    <code value="20149" />
    <display value="Benign Prostatic Hyperplasia (BPH) / Lower Urinary Tract Symptoms (LUTS)" />
  </concept>
  <concept>
    <code value="20150" />
    <display value="Bladder Mass" />
  </concept>
  <concept>
    <code value="20151" />
    <display value="Elevated Prostate-Specific Antigen (PSA) or Suspicious Digital Rectal Exam (DRE)" />
  </concept>
  <concept>
    <code value="20152" />
    <display value="Erectile Dysfunction" />
  </concept>
  <concept>
    <code value="20153" />
    <display value="Hematuria" />
  </concept>
  <concept>
    <code value="20154" />
    <display value="Hydrocele, Varicocele or Spermatocele" />
  </concept>
  <concept>
    <code value="20155" />
    <display value="Hydronephrosis" />
  </concept>
  <concept>
    <code value="20156" />
    <display value="Hypogonadism" />
  </concept>
  <concept>
    <code value="20157" />
    <display value="Infertility - Male" />
  </concept>
  <concept>
    <code value="20158" />
    <display value="Penile Lesion" />
  </concept>
  <concept>
    <code value="20159" />
    <display value="Peyronie's Disease" />
  </concept>
  <concept>
    <code value="20160" />
    <display value="Phimosis, Foreskin Issue or Balanitis" />
  </concept>
  <concept>
    <code value="20161" />
    <display value="Renal Mass or Cyst" />
  </concept>
  <concept>
    <code value="20162" />
    <display value="Nephrolithiasis / Renal Colic" />
  </concept>
  <concept>
    <code value="20163" />
    <display value="Testicular Mass" />
  </concept>
  <concept>
    <code value="20164" />
    <display value="Urinary Incontinence or Overactive Bladder" />
  </concept>
  <concept>
    <code value="20165" />
    <display value="Urinary Tract Infections - Recurrent" />
  </concept>
  <concept>
    <code value="20166" />
    <display value="Vasectomy" />
  </concept>
  <concept>
    <code value="20167" />
    <display value="Gross" />
  </concept>
  <concept>
    <code value="20168" />
    <display value="Microscopic" />
  </concept>
  <concept>
    <code value="20169" />
    <display value="Imaging demonstrates an obstructive stone" />
  </concept>
  <concept>
    <code value="20170" />
    <display value="Neurodiagnostic Testing - Triage to Consult if Appropriate" />
  </concept>
  <concept>
    <code value="20171" />
    <display value="Neurodiagnostic Testing Only (EEG, EMG/NCS)" />
  </concept>
  <concept>
    <code value="20172" />
    <display value="Neurology Consultation" />
  </concept>
  <concept>
    <code value="20173" />
    <display value="Electroencephalography (EEG)" />
  </concept>
  <concept>
    <code value="20174" />
    <display value="Electromyography (EMG) / Nerve Conduction Study (NCS)" />
  </concept>
  <concept>
    <code value="20175" />
    <display value="Routine EEG" />
  </concept>
  <concept>
    <code value="20176" />
    <display value="Sleep Deprived EEG" />
  </concept>
  <concept>
    <code value="20177" />
    <display value="Carpal Tunnel Syndrome" />
  </concept>
  <concept>
    <code value="20178" />
    <display value="Cervical Radiculopathy" />
  </concept>
  <concept>
    <code value="20179" />
    <display value="Lumbar Radiculopathy" />
  </concept>
  <concept>
    <code value="20180" />
    <display value="Peripheral Neuropathy / Polyneuropathy" />
  </concept>
  <concept>
    <code value="20181" />
    <display value="Balance, Dizziness, or Vertigo" />
  </concept>
  <concept>
    <code value="20182" />
    <display value="Concussion or Traumatic Brain Injury (TBI)" />
  </concept>
  <concept>
    <code value="20183" />
    <display value="Epilepsy or Seizure" />
  </concept>
  <concept>
    <code value="20184" />
    <display value="Headache or Migraines" />
  </concept>
  <concept>
    <code value="20185" />
    <display value="Movement Disorders (including Parkinson's and Tremors)" />
  </concept>
  <concept>
    <code value="20186" />
    <display value="Multiple Sclerosis or Demyelinating Disease" />
  </concept>
  <concept>
    <code value="20187" />
    <display value="Neurocognitive Disorder" />
  </concept>
  <concept>
    <code value="20188" />
    <display value="Neuropathy or Weakness" />
  </concept>
  <concept>
    <code value="20190" />
    <display value="Stroke or TIA" />
  </concept>
  <concept>
    <code value="20191" />
    <display value="Crystal Arthropathies (Gout, Pseudogout)" />
  </concept>
  <concept>
    <code value="20192" />
    <display value="Connective Tissue Diseases (Lupus, Sjogren's, Scleroderma, Inflammatory Myositis)" />
  </concept>
  <concept>
    <code value="20193" />
    <display value="Corticosteroid Injections (Osteoarthritis / Tendinitis / Bursitis / Joint Injections)" />
  </concept>
  <concept>
    <code value="20194" />
    <display value="Giant Cell Arteritis" />
  </concept>
  <concept>
    <code value="20195" />
    <display value="Inflammatory Arthritis (e.g. Rheumatoid Arthritis)" />
  </concept>
  <concept>
    <code value="20196" />
    <display value="Polymyalgia Rheumatica" />
  </concept>
  <concept>
    <code value="20197" />
    <display value="Psoriatic Arthritis" />
  </concept>
  <concept>
    <code value="20198" />
    <display value="Spondyloarthritis" />
  </concept>
  <concept>
    <code value="20199" />
    <display value="Vasculitis" />
  </concept>
  <concept>
    <code value="20200" />
    <display value="= 3 attacks in the last year" />
  </concept>
  <concept>
    <code value="20201" />
    <display value="Alopecia / sicca / oral ulcers" />
  </concept>
  <concept>
    <code value="20202" />
    <display value="Arterial / venous thrombosis" />
  </concept>
  <concept>
    <code value="20203" />
    <display value="Glomerulonephritis" />
  </concept>
  <concept>
    <code value="20204" />
    <display value="Hemolytic anemia / ITP" />
  </concept>
  <concept>
    <code value="20205" />
    <display value="Inflammatory Arthritis" />
  </concept>
  <concept>
    <code value="20207" />
    <display value="Objective proximal muscle weakness and high CK" />
  </concept>
  <concept>
    <code value="20208" />
    <display value="Pericarditis / pleural effusions" />
  </concept>
  <concept>
    <code value="20209" />
    <display value="Photosensitivity and rash" />
  </concept>
  <concept>
    <code value="20210" />
    <display value="Pregnancy loss (recurrent)" />
  </concept>
  <concept>
    <code value="20211" />
    <display value="Raynaud�s phenomenon" />
  </concept>
  <concept>
    <code value="20212" />
    <display value="Sclerodactyly / puffy fingers" />
  </concept>
  <concept>
    <code value="20213" />
    <display value="Referred for temporal artery biopsy or ultrasound" />
  </concept>
  <concept>
    <code value="20214" />
    <display value="Vision loss or diplopia" />
  </concept>
  <concept>
    <code value="20215" />
    <display value="New headache" />
  </concept>
  <concept>
    <code value="20216" />
    <display value="Jaw claudication" />
  </concept>
  <concept>
    <code value="20217" />
    <display value="Scalp tenderness" />
  </concept>
  <concept>
    <code value="20218" />
    <display value="Significant weight loss or malaise" />
  </concept>
  <concept>
    <code value="20219" />
    <display value="Unexplained dry cough" />
  </concept>
  <concept>
    <code value="20220" />
    <display value="Ankylosing Spondylitis" />
  </concept>
  <concept>
    <code value="20221" />
    <display value="Reactive Arthritis" />
  </concept>
  <concept>
    <code value="20222" />
    <display value="IBD Related Arthritis" />
  </concept>
  <concept>
    <code value="20223" />
    <display value="Contraception" />
  </concept>
  <concept>
    <code value="20224" />
    <display value="Fertility and Infertility" />
  </concept>
  <concept>
    <code value="20225" />
    <display value="Gynecology" />
  </concept>
  <concept>
    <code value="20226" />
    <display value="Obstetrics (Routine)" />
  </concept>
  <concept>
    <code value="20227" />
    <display value="Obstetrics (High Risk)" />
  </concept>
  <concept>
    <code value="20228" />
    <display value="Pregnancy Termination" />
  </concept>
  <concept>
    <code value="20229" />
    <display value="Transgender Care" />
  </concept>
  <concept>
    <code value="20230" />
    <display value="Contraceptive Counselling" />
  </concept>
  <concept>
    <code value="20231" />
    <display value="IUD Insertion" />
  </concept>
  <concept>
    <code value="20232" />
    <display value="IUD Removal" />
  </concept>
  <concept>
    <code value="20233" />
    <display value="Contraceptive Implant Insertion" />
  </concept>
  <concept>
    <code value="20234" />
    <display value="Contraceptive Implant Removal" />
  </concept>
  <concept>
    <code value="20235" />
    <display value="Fertility Status Evaluation" />
  </concept>
  <concept>
    <code value="20236" />
    <display value="Recurrent Pregnancy Loss" />
  </concept>
  <concept>
    <code value="20237" />
    <display value="Abnormal Cervical Cancer Screening" />
  </concept>
  <concept>
    <code value="20238" />
    <display value="Abnormal Uterine Bleeding" />
  </concept>
  <concept>
    <code value="20239" />
    <display value="Adnexal Mass or Cyst" />
  </concept>
  <concept>
    <code value="20240" />
    <display value="Amenorrhea" />
  </concept>
  <concept>
    <code value="20241" />
    <display value="Dyspareunia or Vaginismus" />
  </concept>
  <concept>
    <code value="20242" />
    <display value="Early Pregnancy Loss or Complication" />
  </concept>
  <concept>
    <code value="20243" />
    <display value="Endometriosis or Pelvic Pain" />
  </concept>
  <concept>
    <code value="20244" />
    <display value="Menopause Management (including Hormone Replacement Therapy)" />
  </concept>
  <concept>
    <code value="20245" />
    <display value="Pelvic Inflammatory Disease" />
  </concept>
  <concept>
    <code value="20246" />
    <display value="Polycystic Ovarian Syndrome (PCOS)" />
  </concept>
  <concept>
    <code value="20247" />
    <display value="Post-Menopausal Bleeding" />
  </concept>
  <concept>
    <code value="20248" />
    <display value="Pelvic Organ Prolapse or Pessary Management" />
  </concept>
  <concept>
    <code value="20249" />
    <display value="Urinary Incontinence" />
  </concept>
  <concept>
    <code value="20250" />
    <display value="Uterine Fibroids, Polyps, Septum, or Other Structural Abnormalities" />
  </concept>
  <concept>
    <code value="20251" />
    <display value="Vaginitis" />
  </concept>
  <concept>
    <code value="20252" />
    <display value="Vulvar, Vaginal, or Cervical Disorders" />
  </concept>
  <concept>
    <code value="20253" />
    <display value="Total Antenatal Care" />
  </concept>
  <concept>
    <code value="20254" />
    <display value="Shared Antenatal Care" />
  </concept>
  <concept>
    <code value="20255" />
    <display value="Obstetrical Consult" />
  </concept>
  <concept>
    <code value="20256" />
    <display value="Last Menstrual Period (LMP)" />
  </concept>
  <concept>
    <code value="20257" />
    <display value="Estimated Date of Delivery (EDD)" />
  </concept>
  <concept>
    <code value="20258" />
    <display value="GTPAL" />
  </concept>
  <concept>
    <code value="20259" />
    <display value="Abnormal Prenatal Screen" />
  </concept>
  <concept>
    <code value="20260" />
    <display value="Congenital Abnormalities" />
  </concept>
  <concept>
    <code value="20261" />
    <display value="Diabetes (pre-existing)" />
  </concept>
  <concept>
    <code value="20262" />
    <display value="Gestational Diabetes" />
  </concept>
  <concept>
    <code value="20263" />
    <display value="HIV Pregnancy" />
  </concept>
  <concept>
    <code value="20265" />
    <display value="Infectious Disease" />
  </concept>
  <concept>
    <code value="20266" />
    <display value="Intrauterine Growth Restriction" />
  </concept>
  <concept>
    <code value="20267" />
    <display value="Medical Disease in Pregnancy" />
  </concept>
  <concept>
    <code value="20268" />
    <display value="Multiple Gestation (Twins, Triplets, Higher Order)" />
  </concept>
  <concept>
    <code value="20269" />
    <display value="Placental Abnormalities" />
  </concept>
  <concept>
    <code value="20270" />
    <display value="Pre-Conception Counselling" />
  </concept>
  <concept>
    <code value="20271" />
    <display value="Substance Abuse in Pregnancy" />
  </concept>
  <concept>
    <code value="20272" />
    <display value="Current gestational age" />
  </concept>
  <concept>
    <code value="20273" />
    <display value="Bicytopenia or Pancytopenia (decreases in more than one cell line)" />
  </concept>
  <concept>
    <code value="20274" />
    <display value="Bleeding or Abnormal INR/PTT" />
  </concept>
  <concept>
    <code value="20275" />
    <display value="Confirmed Malignant Hematology Consultation (biopsy proven)" />
  </concept>
  <concept>
    <code value="20276" />
    <display value="Red Blood Cells or Iron" />
  </concept>
  <concept>
    <code value="20277" />
    <display value="Myeloma or Paraproteinemia (e.g. Bence Jones proteinuria, monoclonal gammopathy)" />
  </concept>
  <concept>
    <code value="20278" />
    <display value="Lymph Nodes or Spleen" />
  </concept>
  <concept>
    <code value="20279" />
    <display value="Platelets" />
  </concept>
  <concept>
    <code value="20280" />
    <display value="Thrombosis" />
  </concept>
  <concept>
    <code value="20281" />
    <display value="Transfusion" />
  </concept>
  <concept>
    <code value="20282" />
    <display value="White Blood Cells" />
  </concept>
  <concept>
    <code value="20283" />
    <display value="Other Benign Hematology Consultation" />
  </concept>
  <concept>
    <code value="20284" />
    <display value="Other Malignant Hematology Consultation" />
  </concept>
  <concept>
    <code value="20285" />
    <display value="Labs abnormal - no bleeding / bruising" />
  </concept>
  <concept>
    <code value="20286" />
    <display value="Abnormal bleeding / bruising" />
  </concept>
  <concept>
    <code value="20287" />
    <display value="Anemia NYD" />
  </concept>
  <concept>
    <code value="20288" />
    <display value="Anemia - Iron Deficiency" />
  </concept>
  <concept>
    <code value="20289" />
    <display value="Erythrocytosis" />
  </concept>
  <concept>
    <code value="20290" />
    <display value="Ferritin - High" />
  </concept>
  <concept>
    <code value="20291" />
    <display value="Hemoglobinopathy" />
  </concept>
  <concept>
    <code value="20292" />
    <display value="Sickle Cell Disease" />
  </concept>
  <concept>
    <code value="20293" />
    <display value="Thallasemias" />
  </concept>
  <concept>
    <code value="20294" />
    <display value="Other Hemoglobinopathy" />
  </concept>
  <concept>
    <code value="20295" />
    <display value="Lymphadenopathy - Concern for Lymphoma" />
  </concept>
  <concept>
    <code value="20296" />
    <display value="Lymphoma" />
  </concept>
  <concept>
    <code value="20297" />
    <display value="Splenomegaly" />
  </concept>
  <concept>
    <code value="20298" />
    <display value="Thrombocytopenia (low platelets)" />
  </concept>
  <concept>
    <code value="20299" />
    <display value="Thrombocytosis (high platelets)" />
  </concept>
  <concept>
    <code value="20300" />
    <display value="Atrial Fibrillation Anticoagulation" />
  </concept>
  <concept>
    <code value="20301" />
    <display value="Mechanical Valve Anticoagulation" />
  </concept>
  <concept>
    <code value="20302" />
    <display value="Peripartum Thrombosis - Prevention or Treatment" />
  </concept>
  <concept>
    <code value="20303" />
    <display value="Peri-procedure Anticoagulation Management" />
  </concept>
  <concept>
    <code value="20304" />
    <display value="Superficial Vein Thrombosis" />
  </concept>
  <concept>
    <code value="20305" />
    <display value="Thrombophilia" />
  </concept>
  <concept>
    <code value="20306" />
    <display value="Venous Thromboembolism - Acute - Imaging Confirmed (e.g. DVT, PE)" />
  </concept>
  <concept>
    <code value="20307" />
    <display value="Venous Thromboembolism - Chronic (e.g. DVT, PE)" />
  </concept>
  <concept>
    <code value="20308" />
    <display value="Other Thrombosis Consultation" />
  </concept>
  <concept>
    <code value="20309" />
    <display value="Acute Leukemia (myeloid or lymphoblastic)" />
  </concept>
  <concept>
    <code value="20310" />
    <display value="Chronic Leukemia (myeloid or lymphoblastic)" />
  </concept>
  <concept>
    <code value="20311" />
    <display value="Leukocytosis (high white blood cells)" />
  </concept>
  <concept>
    <code value="20312" />
    <display value="Leukopenia (low white blood cells, including low neutrophil count)" />
  </concept>
  <concept>
    <code value="20313" />
    <display value="Acute Kidney Injury (AKI)" />
  </concept>
  <concept>
    <code value="20314" />
    <display value="Chronic Kidney Disease (CKD)" />
  </concept>
  <concept>
    <code value="20315" />
    <display value="Electrolyte Disorders" />
  </concept>
  <concept>
    <code value="20318" />
    <display value="Imaging Abnormalities" />
  </concept>
  <concept>
    <code value="20319" />
    <display value="Kidney Stones" />
  </concept>
  <concept>
    <code value="20320" />
    <display value="Proteinuria" />
  </concept>
  <concept>
    <code value="20321" />
    <display value="Suspected Glomerulonephritis/Renal Vasculitis" />
  </concept>
  <concept>
    <code value="20322" />
    <display value="Rapidly worsening kidney function, confirmed on repeat testing in absence of remediable causes" />
  </concept>
  <concept>
    <code value="20323" />
    <display value="ACR = 60 � Persistent for = 3 months" />
  </concept>
  <concept>
    <code value="20324" />
    <display value="eGFR &lt; 30 � Persistent for = 3 months" />
  </concept>
  <concept>
    <code value="20325" />
    <display value="eGFR &lt; 45 and confirmed decline of = 5 within 6 months" />
  </concept>
  <concept>
    <code value="20326" />
    <display value="eGFR &lt; 45 and age = 50 without CKD risk factors" />
  </concept>
  <concept>
    <code value="20327" />
    <display value="5-year KFRE = 5%" />
  </concept>
  <concept>
    <code value="20328" />
    <display value="Gross (suggest Urology referral first for those &gt; 40 years of age)" />
  </concept>
  <concept>
    <code value="20329" />
    <display value="Microscopic &gt; 10 RBC/hpf - confirmed by microscopy" />
  </concept>
  <concept>
    <code value="20330" />
    <display value="Resistant" />
  </concept>
  <concept>
    <code value="20331" />
    <display value="Suspected Secondary Hypertension" />
  </concept>
  <concept>
    <code value="20332" />
    <display value="Multicystic / Polycystic kidneys" />
  </concept>
  <concept>
    <code value="20333" />
    <display value="Shrunken / Atrophic kidney" />
  </concept>
  <concept>
    <code value="20334" />
    <display value="Metabolic work-up for recurrent stones" />
  </concept>
  <concept>
    <code value="20335" />
    <display value="ACR = 30 without Diabetes Mellitus � Persistent for = 3 months" />
  </concept>
  <concept>
    <code value="20336" />
    <display value="24-hour urine protein = 1 g" />
  </concept>
  <concept>
    <code value="20337" />
    <display value="Hematuria with = 10 RBC/hpf � Confirmed by microscopy" />
  </concept>
  <concept>
    <code value="20338" />
    <display value="Urine ACR" />
  </concept>
  <concept>
    <code value="20339" />
    <display value="eGFR" />
  </concept>
  <concept>
    <code value="20340" />
    <display value="Potassium" />
  </concept>
  <concept>
    <code value="20341" />
    <display value="Shoulder" />
  </concept>
  <concept>
    <code value="20342" />
    <display value="Arm" />
  </concept>
  <concept>
    <code value="20343" />
    <display value="Elbow" />
  </concept>
  <concept>
    <code value="20344" />
    <display value="Forearm" />
  </concept>
  <concept>
    <code value="20345" />
    <display value="Wrist" />
  </concept>
  <concept>
    <code value="20346" />
    <display value="Hand" />
  </concept>
  <concept>
    <code value="20347" />
    <display value="Spine" />
  </concept>
  <concept>
    <code value="20348" />
    <display value="Pelvis" />
  </concept>
  <concept>
    <code value="20349" />
    <display value="Hip" />
  </concept>
  <concept>
    <code value="20350" />
    <display value="Thigh" />
  </concept>
  <concept>
    <code value="20351" />
    <display value="Knee" />
  </concept>
  <concept>
    <code value="20352" />
    <display value="Leg" />
  </concept>
  <concept>
    <code value="20353" />
    <display value="Ankle / Hindfoot" />
  </concept>
  <concept>
    <code value="20354" />
    <display value="Midfoot / Forefoot" />
  </concept>
  <concept>
    <code value="20355" />
    <display value="Fracture" />
  </concept>
  <concept>
    <code value="20356" />
    <display value="Joint Instability / Subluxation" />
  </concept>
  <concept>
    <code value="20357" />
    <display value="Osteoarthritis" />
  </concept>
  <concept>
    <code value="20358" />
    <display value="Pain NYD" />
  </concept>
  <concept>
    <code value="20359" />
    <display value="Rotator Cuff / Impingement" />
  </concept>
  <concept>
    <code value="20360" />
    <display value="Post-traumatic arthritis" />
  </concept>
  <concept>
    <code value="20362" />
    <display value="De Quervain�s Tenosynovitis" />
  </concept>
  <concept>
    <code value="20363" />
    <display value="Ganglion Cyst" />
  </concept>
  <concept>
    <code value="20364" />
    <display value="Dupuytren�s Contracture" />
  </concept>
  <concept>
    <code value="20365" />
    <display value="Finger Deformity" />
  </concept>
  <concept>
    <code value="20366" />
    <display value="Flexor Tendon Injury" />
  </concept>
  <concept>
    <code value="20367" />
    <display value="Trigger Finger" />
  </concept>
  <concept>
    <code value="20368" />
    <display value="Cervical Spine" />
  </concept>
  <concept>
    <code value="20369" />
    <display value="Thoracic Spine" />
  </concept>
  <concept>
    <code value="20370" />
    <display value="Lumbar Spine" />
  </concept>
  <concept>
    <code value="20371" />
    <display value="Deformity / Scoliosis / Kyphosis" />
  </concept>
  <concept>
    <code value="20372" />
    <display value="Myelopathy" />
  </concept>
  <concept>
    <code value="20373" />
    <display value="Neurogenic Claudication" />
  </concept>
  <concept>
    <code value="20374" />
    <display value="Spondylolisthesis" />
  </concept>
  <concept>
    <code value="20375" />
    <display value="Stenosis" />
  </concept>
  <concept>
    <code value="20377" />
    <display value="ACL Tear" />
  </concept>
  <concept>
    <code value="20378" />
    <display value="Cartilage Injury" />
  </concept>
  <concept>
    <code value="20376" />
    <display value="Knee Malalignment" />
  </concept>
  <concept>
    <code value="20379" />
    <display value="Loose Bodies" />
  </concept>
  <concept>
    <code value="20380" />
    <display value="Meniscal Tear" />
  </concept>
  <concept>
    <code value="20381" />
    <display value="Multi-Ligament Injury" />
  </concept>
  <concept>
    <code value="20382" />
    <display value="Achilles Tendinopathy" />
  </concept>
  <concept>
    <code value="20383" />
    <display value="Joint Instability" />
  </concept>
  <concept>
    <code value="20384" />
    <display value="Bunion" />
  </concept>
  <concept>
    <code value="20385" />
    <display value="Charcot Foot" />
  </concept>
  <concept>
    <code value="20386" />
    <display value="Flatfoot / Pes Planus" />
  </concept>
  <concept>
    <code value="20387" />
    <display value="Metatarsalgia" />
  </concept>
  <concept>
    <code value="20388" />
    <display value="Plantar Fasciitis" />
  </concept>
  <concept>
    <code value="20389" />
    <display value="Toe Deformity" />
  </concept>
  <concept>
    <code value="20390" />
    <display value="CT Requisition" />
    <designation>
      <language value="fr" />
      <value value="Demande de TDM" />
    </designation>
  </concept>
  <concept>
    <code value="20391" />
    <display value="MRI Requisition" />
    <designation>
      <language value="fr" />
      <value value="Demande d'IRM" />
    </designation>
  </concept>
  <concept>
    <code value="20392" />
    <display value="X-Ray Requisition" />
    <designation>
      <language value="fr" />
      <value value="Demande de radiographie" />
    </designation>
  </concept>
  <concept>
    <code value="20393" />
    <display value="Ultrasound Requisition" />
    <designation>
      <language value="fr" />
      <value value="Demande d'échographie" />
    </designation>
  </concept>
  <concept>
    <code value="20394" />
    <display value="Bone Mineral Density Requisition" />
    <designation>
      <language value="fr" />
      <value value="Demande de densitométrie osseuse" />
    </designation>
  </concept>
  <concept>
    <code value="20395" />
    <display value="Head" />
    <designation>
      <language value="fr" />
      <value value="Tête" />
    </designation>
  </concept>
  <concept>
    <code value="20396" />
    <display value="Neck" />
    <designation>
      <language value="fr" />
      <value value="Cou" />
    </designation>
  </concept>
  <concept>
    <code value="20397" />
    <display value="Spine" />
    <designation>
      <language value="fr" />
      <value value="Colonne vertébrale" />
    </designation>
  </concept>
  <concept>
    <code value="20398" />
    <display value="Thorax" />
    <designation>
      <language value="fr" />
      <value value="Thorax" />
    </designation>
  </concept>
  <concept>
    <code value="20399" />
    <display value="Abdomen Pelvis" />
    <designation>
      <language value="fr" />
      <value value="Abdomen Bassin" />
    </designation>
  </concept>
  <concept>
    <code value="20400" />
    <display value="Musculoskeletal" />
    <designation>
      <language value="fr" />
      <value value="Musculosquelettique" />
    </designation>
  </concept>
  <concept>
    <code value="20401" />
    <display value="Angiography" />
    <designation>
      <language value="fr" />
      <value value="Angiographie" />
    </designation>
  </concept>
  <concept>
    <code value="20403" />
    <display value="Whole-Body Low-Dose (Myeloma)" />
    <designation>
      <language value="fr" />
      <value value="Corps entier faible dose (Myélome)" />
    </designation>
  </concept>
  <concept>
    <code value="20404" />
    <display value="Cardiac" />
    <designation>
      <language value="fr" />
      <value value="Cardiaque" />
    </designation>
  </concept>
  <concept>
    <code value="20405" />
    <display value="Biopsy" />
    <designation>
      <language value="fr" />
      <value value="Biopsie" />
    </designation>
  </concept>
  <concept>
    <code value="20406" />
    <display value="Brain" />
    <designation>
      <language value="fr" />
      <value value="Cerveau" />
    </designation>
  </concept>
  <concept>
    <code value="20408" />
    <display value="Facial bones" />
    <designation>
      <language value="fr" />
      <value value="Os du visage" />
    </designation>
  </concept>
  <concept>
    <code value="20409" />
    <display value="Internal auditory canals" />
    <designation>
      <language value="fr" />
      <value value="Canaux auditifs internes" />
    </designation>
  </concept>
  <concept>
    <code value="20410" />
    <display value="Orbits" />
    <designation>
      <language value="fr" />
      <value value="Orbites" />
    </designation>
  </concept>
  <concept>
    <code value="20411" />
    <display value="Sinuses" />
    <designation>
      <language value="fr" />
      <value value="Sinus" />
    </designation>
  </concept>
  <concept>
    <code value="20412" />
    <display value="Temporal bones" />
    <designation>
      <language value="fr" />
      <value value="Os temporaux" />
    </designation>
  </concept>
  <concept>
    <code value="20414" />
    <display value="Soft Tissue Neck" />
    <designation>
      <language value="fr" />
      <value value="Tissus mous du cou" />
    </designation>
  </concept>
  <concept>
    <code value="20415" />
    <display value="Cervical Spine" />
    <designation>
      <language value="fr" />
      <value value="Colonne cervicale" />
    </designation>
  </concept>
  <concept>
    <code value="20416" />
    <display value="Thoracic Spine" />
    <designation>
      <language value="fr" />
      <value value="Colonne thoracique" />
    </designation>
  </concept>
  <concept>
    <code value="20417" />
    <display value="Lumbar Spine" />
    <designation>
      <language value="fr" />
      <value value="Colonne lombaire" />
    </designation>
  </concept>
  <concept>
    <code value="20418" />
    <display value="Sacrum/Coccyx" />
    <designation>
      <language value="fr" />
      <value value="Sacrum/Coccyx" />
    </designation>
  </concept>
  <concept>
    <code value="20419" />
    <display value="Sacroiliac Joints" />
    <designation>
      <language value="fr" />
      <value value="Articulations sacro-iliaques" />
    </designation>
  </concept>
  <concept>
    <code value="20420" />
    <display value="Chest" />
    <designation>
      <language value="fr" />
      <value value="Thorax" />
    </designation>
  </concept>
  <concept>
    <code value="20421" />
    <display value="Chest High Resolution" />
    <designation>
      <language value="fr" />
      <value value="Thorax haute résolution" />
    </designation>
  </concept>
  <concept>
    <code value="20422" />
    <display value="Chest Low-Dose" />
    <designation>
      <language value="fr" />
      <value value="Thorax faible dose" />
    </designation>
  </concept>
  <concept>
    <code value="20423" />
    <display value="Pulmonary Embolism" />
    <designation>
      <language value="fr" />
      <value value="Embolie pulmonaire" />
    </designation>
  </concept>
  <concept>
    <code value="20425" />
    <display value="Thoracic Outlet" />
    <designation>
      <language value="fr" />
      <value value="Défilé thoracique" />
    </designation>
  </concept>
  <concept>
    <code value="20426" />
    <display value="Chest Abdomen Pelvis" />
    <designation>
      <language value="fr" />
      <value value="Thorax Abdomen Bassin" />
    </designation>
  </concept>
  <concept>
    <code value="20427" />
    <display value="Abdomen only" />
    <designation>
      <language value="fr" />
      <value value="Abdomen seulement" />
    </designation>
  </concept>
  <concept>
    <code value="20428" />
    <display value="Pelvis only" />
    <designation>
      <language value="fr" />
      <value value="Bassin seulement" />
    </designation>
  </concept>
  <concept>
    <code value="20430" />
    <display value="Colonography" />
    <designation>
      <language value="fr" />
      <value value="Colonographie" />
    </designation>
  </concept>
  <concept>
    <code value="20431" />
    <display value="Enterography" />
    <designation>
      <language value="fr" />
      <value value="Entérographie" />
    </designation>
  </concept>
  <concept>
    <code value="20432" />
    <display value="Renal Colic" />
    <designation>
      <language value="fr" />
      <value value="Colique rénale" />
    </designation>
  </concept>
  <concept>
    <code value="20433" />
    <display value="Urography" />
    <designation>
      <language value="fr" />
      <value value="Urographie" />
    </designation>
  </concept>
  <concept>
    <code value="20434" />
    <display value="Shoulder" />
    <designation>
      <language value="fr" />
      <value value="Épaule" />
    </designation>
  </concept>
  <concept>
    <code value="20435" />
    <display value="Humerus" />
    <designation>
      <language value="fr" />
      <value value="Humérus" />
    </designation>
  </concept>
  <concept>
    <code value="20436" />
    <display value="Elbow" />
    <designation>
      <language value="fr" />
      <value value="Coude" />
    </designation>
  </concept>
  <concept>
    <code value="20437" />
    <display value="Forearm" />
    <designation>
      <language value="fr" />
      <value value="Avant-bras" />
    </designation>
  </concept>
  <concept>
    <code value="20438" />
    <display value="Wrist" />
    <designation>
      <language value="fr" />
      <value value="Poignet" />
    </designation>
  </concept>
  <concept>
    <code value="20439" />
    <display value="Hand" />
    <designation>
      <language value="fr" />
      <value value="Main" />
    </designation>
  </concept>
  <concept>
    <code value="20440" />
    <display value="Bony Pelvis" />
    <designation>
      <language value="fr" />
      <value value="Bassin osseux" />
    </designation>
  </concept>
  <concept>
    <code value="20441" />
    <display value="Hip" />
    <designation>
      <language value="fr" />
      <value value="Hanche" />
    </designation>
  </concept>
  <concept>
    <code value="20442" />
    <display value="Femur" />
    <designation>
      <language value="fr" />
      <value value="Fémur" />
    </designation>
  </concept>
  <concept>
    <code value="20443" />
    <display value="Knee" />
    <designation>
      <language value="fr" />
      <value value="Genou" />
    </designation>
  </concept>
  <concept>
    <code value="20444" />
    <display value="Tibia and Fibula" />
    <designation>
      <language value="fr" />
      <value value="Tibia et fibula" />
    </designation>
  </concept>
  <concept>
    <code value="20445" />
    <display value="Ankle" />
    <designation>
      <language value="fr" />
      <value value="Cheville" />
    </designation>
  </concept>
  <concept>
    <code value="20446" />
    <display value="Foot" />
    <designation>
      <language value="fr" />
      <value value="Pied" />
    </designation>
  </concept>
  <concept>
    <code value="20447" />
    <display value="Head Angiography" />
    <designation>
      <language value="fr" />
      <value value="Angiographie de la tête" />
    </designation>
  </concept>
  <concept>
    <code value="20448" />
    <display value="Neck Angiography" />
    <designation>
      <language value="fr" />
      <value value="Angiographie du cou" />
    </designation>
  </concept>
  <concept>
    <code value="20449" />
    <display value="Chest Angiography" />
    <designation>
      <language value="fr" />
      <value value="Angiographie du thorax" />
    </designation>
  </concept>
  <concept>
    <code value="20450" />
    <display value="Chest Abdomen Pelvis Angiography" />
    <designation>
      <language value="fr" />
      <value value="Angiographie thorax abdomen bassin" />
    </designation>
  </concept>
  <concept>
    <code value="20451" />
    <display value="Abdomen Angiography" />
    <designation>
      <language value="fr" />
      <value value="Angiographie de l'abdomen" />
    </designation>
  </concept>
  <concept>
    <code value="20452" />
    <display value="Abdomen Pelvis Angiography" />
    <designation>
      <language value="fr" />
      <value value="Angiographie abdomen bassin" />
    </designation>
  </concept>
  <concept>
    <code value="20453" />
    <display value="Pelvis Angiography" />
    <designation>
      <language value="fr" />
      <value value="Angiographie du bassin" />
    </designation>
  </concept>
  <concept>
    <code value="20454" />
    <display value="Upper Extremity Angiography" />
    <designation>
      <language value="fr" />
      <value value="Angiographie des membres supérieurs" />
    </designation>
  </concept>
  <concept>
    <code value="20455" />
    <display value="Lower Extremity Angiography" />
    <designation>
      <language value="fr" />
      <value value="Angiographie des membres inférieurs" />
    </designation>
  </concept>
  <concept>
    <code value="20456" />
    <display value="Head Venography" />
    <designation>
      <language value="fr" />
      <value value="Céphalique veineuse" />
    </designation>
  </concept>
  <concept>
    <code value="20464" />
    <display value="Cardiac CT" />
    <designation>
      <language value="fr" />
      <value value="CT cardiaque" />
    </designation>
  </concept>
  <concept>
    <code value="20465" />
    <display value="Coronary Angiography (CCTA)" />
    <designation>
      <language value="fr" />
      <value value="Angiographie coronarienne (CCTA)" />
    </designation>
  </concept>
  <concept>
    <code value="20466" />
    <display value="Cardiac Calcium Score" />
    <designation>
      <language value="fr" />
      <value value="Score calcique cardiaque" />
    </designation>
  </concept>
  <concept>
    <code value="20467" />
    <display value="Head" />
    <designation>
      <language value="fr" />
      <value value="Tête" />
    </designation>
  </concept>
  <concept>
    <code value="20468" />
    <display value="Neck" />
    <designation>
      <language value="fr" />
      <value value="Cou" />
    </designation>
  </concept>
  <concept>
    <code value="20469" />
    <display value="Spine" />
    <designation>
      <language value="fr" />
      <value value="Colonne vertébrale" />
    </designation>
  </concept>
  <concept>
    <code value="20470" />
    <display value="Thorax" />
    <designation>
      <language value="fr" />
      <value value="Thorax" />
    </designation>
  </concept>
  <concept>
    <code value="20471" />
    <display value="Abdomen" />
    <designation>
      <language value="fr" />
      <value value="Abdomen" />
    </designation>
  </concept>
  <concept>
    <code value="20472" />
    <display value="Pelvis" />
    <designation>
      <language value="fr" />
      <value value="Bassin" />
    </designation>
  </concept>
  <concept>
    <code value="20473" />
    <display value="Musculoskeletal" />
    <designation>
      <language value="fr" />
      <value value="Musculosquelettique" />
    </designation>
  </concept>
  <concept>
    <code value="20474" />
    <display value="Angiography" />
    <designation>
      <language value="fr" />
      <value value="Angiographie" />
    </designation>
  </concept>
  <concept>
    <code value="20476" />
    <display value="Breast" />
    <designation>
      <language value="fr" />
      <value value="Sein" />
    </designation>
  </concept>
  <concept>
    <code value="20477" />
    <display value="Cardiac" />
    <designation>
      <language value="fr" />
      <value value="Cardiaque" />
    </designation>
  </concept>
  <concept>
    <code value="20478" />
    <display value="Brain" />
    <designation>
      <language value="fr" />
      <value value="Cerveau" />
    </designation>
  </concept>
  <concept>
    <code value="20480" />
    <display value="Internal auditory canals" />
    <designation>
      <language value="fr" />
      <value value="Canaux auditifs internes" />
    </designation>
  </concept>
  <concept>
    <code value="20481" />
    <display value="Orbits" />
    <designation>
      <language value="fr" />
      <value value="Orbites" />
    </designation>
  </concept>
  <concept>
    <code value="20482" />
    <display value="Pituitary / Sella" />
    <designation>
      <language value="fr" />
      <value value="Hypophyse / Sella" />
    </designation>
  </concept>
  <concept>
    <code value="20483" />
    <display value="Sinuses" />
    <designation>
      <language value="fr" />
      <value value="Sinus" />
    </designation>
  </concept>
  <concept>
    <code value="20484" />
    <display value="Temporomandibular joints" />
    <designation>
      <language value="fr" />
      <value value="Articulations temporo-mandibulaires" />
    </designation>
  </concept>
  <concept>
    <code value="20485" />
    <display value="Trigeminal nerve" />
    <designation>
      <language value="fr" />
      <value value="Nerf trijumeau" />
    </designation>
  </concept>
  <concept>
    <code value="20487" />
    <display value="Soft Tissue Neck" />
    <designation>
      <language value="fr" />
      <value value="Tissu mou du cou" />
    </designation>
  </concept>
  <concept>
    <code value="20488" />
    <display value="Brachial plexus" />
    <designation>
      <language value="fr" />
      <value value="Plexus brachial" />
    </designation>
  </concept>
  <concept>
    <code value="20489" />
    <display value="Whole Spine" />
    <designation>
      <language value="fr" />
      <value value="Colonne vertébrale entière" />
    </designation>
  </concept>
  <concept>
    <code value="20490" />
    <display value="Cervical Spine" />
    <designation>
      <language value="fr" />
      <value value="Colonne cervicale" />
    </designation>
  </concept>
  <concept>
    <code value="20491" />
    <display value="Thoracic Spine" />
    <designation>
      <language value="fr" />
      <value value="Colonne thoracique" />
    </designation>
  </concept>
  <concept>
    <code value="20492" />
    <display value="Lumbar Spine" />
    <designation>
      <language value="fr" />
      <value value="Colonne lombaire" />
    </designation>
  </concept>
  <concept>
    <code value="20493" />
    <display value="Sacrum/Coccyx" />
    <designation>
      <language value="fr" />
      <value value="Sacrum/Coccyx" />
    </designation>
  </concept>
  <concept>
    <code value="20494" />
    <display value="Sacroiliac Joints" />
    <designation>
      <language value="fr" />
      <value value="Articulations sacro-iliaques" />
    </designation>
  </concept>
  <concept>
    <code value="20495" />
    <display value="Chest" />
    <designation>
      <language value="fr" />
      <value value="Thorax" />
    </designation>
  </concept>
  <concept>
    <code value="20496" />
    <display value="Chest wall" />
    <designation>
      <language value="fr" />
      <value value="Paroi thoracique" />
    </designation>
  </concept>
  <concept>
    <code value="20497" />
    <display value="Pulmonary arteries" />
    <designation>
      <language value="fr" />
      <value value="Artères pulmonaires" />
    </designation>
  </concept>
  <concept>
    <code value="20498" />
    <display value="Sternoclavicular joints" />
    <designation>
      <language value="fr" />
      <value value="Articulations sternoclaviculaires" />
    </designation>
  </concept>
  <concept>
    <code value="20499" />
    <display value="Sternum" />
    <designation>
      <language value="fr" />
      <value value="Sternum" />
    </designation>
  </concept>
  <concept>
    <code value="20501" />
    <display value="Thoracic Outlet" />
    <designation>
      <language value="fr" />
      <value value="Défilé thoracique" />
    </designation>
  </concept>
  <concept>
    <code value="20503" />
    <display value="Abdominal wall" />
    <designation>
      <language value="fr" />
      <value value="Paroi abdominale" />
    </designation>
  </concept>
  <concept>
    <code value="20504" />
    <display value="Adrenal glands" />
    <designation>
      <language value="fr" />
      <value value="Glandes surrénales" />
    </designation>
  </concept>
  <concept>
    <code value="20505" />
    <display value="Biliary and pancreatic ducts" />
    <designation>
      <language value="fr" />
      <value value="Voies biliaires et pancréatiques" />
    </designation>
  </concept>
  <concept>
    <code value="20506" />
    <display value="Enterography" />
    <designation>
      <language value="fr" />
      <value value="Entérographie" />
    </designation>
  </concept>
  <concept>
    <code value="20507" />
    <display value="Kidneys" />
    <designation>
      <language value="fr" />
      <value value="Reins" />
    </designation>
  </concept>
  <concept>
    <code value="20508" />
    <display value="Liver" />
    <designation>
      <language value="fr" />
      <value value="Foie" />
    </designation>
  </concept>
  <concept>
    <code value="20509" />
    <display value="Pancreas" />
    <designation>
      <language value="fr" />
      <value value="Pancréas" />
    </designation>
  </concept>
  <concept>
    <code value="20510" />
    <display value="Renal artery" />
    <designation>
      <language value="fr" />
      <value value="Artère rénale" />
    </designation>
  </concept>
  <concept>
    <code value="20511" />
    <display value="Urography" />
    <designation>
      <language value="fr" />
      <value value="Urographie" />
    </designation>
  </concept>
  <concept>
    <code value="20512" />
    <display value="Bladder" />
    <designation>
      <language value="fr" />
      <value value="Vessie" />
    </designation>
  </concept>
  <concept>
    <code value="20513" />
    <display value="Gynecology (Uterus/ Ovaries/ Adnexal)" />
    <designation>
      <language value="fr" />
      <value value="Gynécologie (Utérus/ Ovaires/ Annexes)" />
    </designation>
  </concept>
  <concept>
    <code value="20514" />
    <display value="Iliac arteries" />
    <designation>
      <language value="fr" />
      <value value="Artères iliaques" />
    </designation>
  </concept>
  <concept>
    <code value="20515" />
    <display value="Piriformis" />
    <designation>
      <language value="fr" />
      <value value="Piriforme" />
    </designation>
  </concept>
  <concept>
    <code value="20516" />
    <display value="Prostate" />
    <designation>
      <language value="fr" />
      <value value="Prostate" />
    </designation>
  </concept>
  <concept>
    <code value="20517" />
    <display value="Rectum/ Anal" />
    <designation>
      <language value="fr" />
      <value value="Rectum/ Anal" />
    </designation>
  </concept>
  <concept>
    <code value="20518" />
    <display value="Urogenital (Testicular/ Penile)" />
    <designation>
      <language value="fr" />
      <value value="Urogénital (Testiculaire/ Pénien)" />
    </designation>
  </concept>
  <concept>
    <code value="20519" />
    <display value="Shoulder" />
    <designation>
      <language value="fr" />
      <value value="Épaule" />
    </designation>
  </concept>
  <concept>
    <code value="20520" />
    <display value="Humerus" />
    <designation>
      <language value="fr" />
      <value value="Humérus" />
    </designation>
  </concept>
  <concept>
    <code value="20521" />
    <display value="Elbow" />
    <designation>
      <language value="fr" />
      <value value="Coude" />
    </designation>
  </concept>
  <concept>
    <code value="20522" />
    <display value="Forearm" />
    <designation>
      <language value="fr" />
      <value value="Avant-bras" />
    </designation>
  </concept>
  <concept>
    <code value="20523" />
    <display value="Wrist" />
    <designation>
      <language value="fr" />
      <value value="Poignet" />
    </designation>
  </concept>
  <concept>
    <code value="20524" />
    <display value="Hand" />
    <designation>
      <language value="fr" />
      <value value="Main" />
    </designation>
  </concept>
  <concept>
    <code value="20525" />
    <display value="Finger" />
  </concept>
  <concept>
    <code value="20526" />
    <display value="Bony Pelvis" />
    <designation>
      <language value="fr" />
      <value value="Bassins osseux" />
    </designation>
  </concept>
  <concept>
    <code value="20527" />
    <display value="Hip" />
    <designation>
      <language value="fr" />
      <value value="Hanche" />
    </designation>
  </concept>
  <concept>
    <code value="20528" />
    <display value="Femur / Thigh" />
    <designation>
      <language value="fr" />
      <value value="Fémur / Cuisse" />
    </designation>
  </concept>
  <concept>
    <code value="20529" />
    <display value="Knee" />
    <designation>
      <language value="fr" />
      <value value="Genou" />
    </designation>
  </concept>
  <concept>
    <code value="20530" />
    <display value="Tibia and Fibula" />
    <designation>
      <language value="fr" />
      <value value="Tibia et Fibula" />
    </designation>
  </concept>
  <concept>
    <code value="20531" />
    <display value="Ankle" />
    <designation>
      <language value="fr" />
      <value value="Cheville" />
    </designation>
  </concept>
  <concept>
    <code value="20532" />
    <display value="Foot" />
    <designation>
      <language value="fr" />
      <value value="Pied" />
    </designation>
  </concept>
  <concept>
    <code value="20533" />
    <display value="Toe" />
    <designation>
      <language value="fr" />
      <value value="Orteil" />
    </designation>
  </concept>
  <concept>
    <code value="20534" />
    <display value="Arthrogram" />
    <designation>
      <language value="fr" />
      <value value="Arthrogramme" />
    </designation>
  </concept>
  <concept>
    <code value="20535" />
    <display value="Arthrogram" />
    <designation>
      <language value="fr" />
      <value value="Arthrogramme" />
    </designation>
  </concept>
  <concept>
    <code value="20536" />
    <display value="Arthrogram" />
    <designation>
      <language value="fr" />
      <value value="Arthrogramme" />
    </designation>
  </concept>
  <concept>
    <code value="20537" />
    <display value="Arthrogram" />
    <designation>
      <language value="fr" />
      <value value="Arthrogramme" />
    </designation>
  </concept>
  <concept>
    <code value="20538" />
    <display value="Arthrogram" />
    <designation>
      <language value="fr" />
      <value value="Arthrogramme" />
    </designation>
  </concept>
  <concept>
    <code value="20539" />
    <display value="Arthrogram" />
    <designation>
      <language value="fr" />
      <value value="Arthrogramme" />
    </designation>
  </concept>
  <concept>
    <code value="20540" />
    <display value="Head Angiography" />
    <designation>
      <language value="fr" />
      <value value="Angiographie de la tête" />
    </designation>
  </concept>
  <concept>
    <code value="20541" />
    <display value="Neck Angiography" />
    <designation>
      <language value="fr" />
      <value value="Angiographie du cou" />
    </designation>
  </concept>
  <concept>
    <code value="20542" />
    <display value="Chest Angiography" />
    <designation>
      <language value="fr" />
      <value value="Angiographie thoracique" />
    </designation>
  </concept>
  <concept>
    <code value="20543" />
    <display value="Abdomen Angiography" />
    <designation>
      <language value="fr" />
      <value value="Angiographie abdominale" />
    </designation>
  </concept>
  <concept>
    <code value="20544" />
    <display value="Pelvis Angiography" />
    <designation>
      <language value="fr" />
      <value value="Angiographie pelvienne" />
    </designation>
  </concept>
  <concept>
    <code value="20545" />
    <display value="Upper Extremity Angiography" />
    <designation>
      <language value="fr" />
      <value value="Angiographie des membres supérieurs" />
    </designation>
  </concept>
  <concept>
    <code value="20546" />
    <display value="Lower Extremity Angiography" />
    <designation>
      <language value="fr" />
      <value value="Angiographie des membres inférieurs" />
    </designation>
  </concept>
  <concept>
    <code value="20554" />
    <display value="Diagnostic" />
    <designation>
      <language value="fr" />
      <value value="Diagnostique" />
    </designation>
  </concept>
  <concept>
    <code value="20555" />
    <display value="Implant" />
    <designation>
      <language value="fr" />
      <value value="Implant" />
    </designation>
  </concept>
  <concept>
    <code value="20556" />
    <display value="Chest (default Chest 2 views)" />
    <designation>
      <language value="fr" />
      <value value="Thorax (par défaut Thorax 2 vues)" />
    </designation>
  </concept>
  <concept>
    <code value="20557" />
    <display value="Abdomen" />
    <designation>
      <language value="fr" />
      <value value="Abdomen" />
    </designation>
  </concept>
  <concept>
    <code value="20558" />
    <display value="Spine" />
    <designation>
      <language value="fr" />
      <value value="Colonne vertébrale" />
    </designation>
  </concept>
  <concept>
    <code value="20559" />
    <display value="Head and Neck" />
    <designation>
      <language value="fr" />
      <value value="Tête et cou" />
    </designation>
  </concept>
  <concept>
    <code value="20560" />
    <display value="Upper Extremities" />
    <designation>
      <language value="fr" />
      <value value="Membres supérieurs" />
    </designation>
  </concept>
  <concept>
    <code value="20561" />
    <display value="Lower Extremities" />
    <designation>
      <language value="fr" />
      <value value="Membres inférieurs" />
    </designation>
  </concept>
  <concept>
    <code value="20562" />
    <display value="Mammogram (Non-OBSP)" />
    <designation>
      <language value="fr" />
      <value value="Mammographie (Non-OBSP)" />
    </designation>
  </concept>
  <concept>
    <code value="20563" />
    <display value="Bone Age" />
    <designation>
      <language value="fr" />
      <value value="Âge osseux" />
    </designation>
  </concept>
  <concept>
    <code value="20564" />
    <display value="Survey" />
    <designation>
      <language value="fr" />
      <value value="Examen général" />
    </designation>
  </concept>
  <concept>
    <code value="20565" />
    <display value="Gastric and Fluoroscopic imaging" />
    <designation>
      <language value="fr" />
      <value value="Imagerie gastrique et fluoroscopique" />
    </designation>
  </concept>
  <concept>
    <code value="20566" />
    <display value="One view (PA)" />
    <designation>
      <language value="fr" />
      <value value="Une vue (PA)" />
    </designation>
  </concept>
  <concept>
    <code value="20567" />
    <display value="Two Views (PA, Lat)" />
    <designation>
      <language value="fr" />
      <value value="Deux vues (PA, Lat)" />
    </designation>
  </concept>
  <concept>
    <code value="20568" />
    <display value="Three views (PA inspiration, PA expiration, Lat)" />
    <designation>
      <language value="fr" />
      <value value="Trois vues (PA inspiration, PA expiration, Lat)" />
    </designation>
  </concept>
  <concept>
    <code value="20569" />
    <display value="Sternum" />
    <designation>
      <language value="fr" />
      <value value="Sternum" />
    </designation>
  </concept>
  <concept>
    <code value="20570" />
    <display value="Ribs" />
    <designation>
      <language value="fr" />
      <value value="Côtes" />
    </designation>
  </concept>
  <concept>
    <code value="20571" />
    <display value="Thoracic inlet" />
    <designation>
      <language value="fr" />
      <value value="Orifice thoracique" />
    </designation>
  </concept>
  <concept>
    <code value="20572" />
    <display value="Sternoclavicular Joints" />
    <designation>
      <language value="fr" />
      <value value="Articulations sternoclaviculaires" />
    </designation>
  </concept>
  <concept>
    <code value="20573" />
    <display value="One view (Supine)" />
    <designation>
      <language value="fr" />
      <value value="Une vue (Décubitus)" />
    </designation>
  </concept>
  <concept>
    <code value="20574" />
    <display value="One view (Upright)" />
    <designation>
      <language value="fr" />
      <value value="Une vue (Debout)" />
    </designation>
  </concept>
  <concept>
    <code value="20575" />
    <display value="KUB (Kidney Ureters Bladder)" />
    <designation>
      <language value="fr" />
      <value value="KUB (Rein Uretères Vessie)" />
    </designation>
  </concept>
  <concept>
    <code value="20576" />
    <display value="Cervical" />
    <designation>
      <language value="fr" />
      <value value="Cervical" />
    </designation>
  </concept>
  <concept>
    <code value="20577" />
    <display value="Cervical spine flexion extension" />
    <designation>
      <language value="fr" />
      <value value="Flexion extension de la colonne cervicale" />
    </designation>
  </concept>
  <concept>
    <code value="20578" />
    <display value="Thoracic" />
    <designation>
      <language value="fr" />
      <value value="Thoracique" />
    </designation>
  </concept>
  <concept>
    <code value="20579" />
    <display value="Lumbar" />
    <designation>
      <language value="fr" />
      <value value="Lombaire" />
    </designation>
  </concept>
  <concept>
    <code value="20580" />
    <display value="Lumbar spine flexion extension" />
    <designation>
      <language value="fr" />
      <value value="Flexion extension de la colonne lombaire" />
    </designation>
  </concept>
  <concept>
    <code value="20581" />
    <display value="Sacrum" />
    <designation>
      <language value="fr" />
      <value value="Sacrum" />
    </designation>
  </concept>
  <concept>
    <code value="20582" />
    <display value="Coccyx" />
    <designation>
      <language value="fr" />
      <value value="Coccyx" />
    </designation>
  </concept>
  <concept>
    <code value="20583" />
    <display value="Sacroiliac joints" />
    <designation>
      <language value="fr" />
      <value value="Articulations sacro-iliaques" />
    </designation>
  </concept>
  <concept>
    <code value="20584" />
    <display value="Scoliosis spine" />
    <designation>
      <language value="fr" />
      <value value="Colonne vertébrale scoliose" />
    </designation>
  </concept>
  <concept>
    <code value="20585" />
    <display value="Skull" />
    <designation>
      <language value="fr" />
      <value value="Crâne" />
    </designation>
  </concept>
  <concept>
    <code value="20586" />
    <display value="Orbits" />
    <designation>
      <language value="fr" />
      <value value="Orbites" />
    </designation>
  </concept>
  <concept>
    <code value="20587" />
    <display value="Neck for soft tissue" />
    <designation>
      <language value="fr" />
      <value value="Cou pour les tissus mous" />
    </designation>
  </concept>
  <concept>
    <code value="20588" />
    <display value="Mastoids" />
    <designation>
      <language value="fr" />
      <value value="Mastoïdes" />
    </designation>
  </concept>
  <concept>
    <code value="20589" />
    <display value="Nasal bones" />
    <designation>
      <language value="fr" />
      <value value="Os nasaux" />
    </designation>
  </concept>
  <concept>
    <code value="20590" />
    <display value="Facal bones" />
    <designation>
      <language value="fr" />
      <value value="Os faciaux" />
    </designation>
  </concept>
  <concept>
    <code value="20591" />
    <display value="Mandible" />
    <designation>
      <language value="fr" />
      <value value="Mandibule" />
    </designation>
  </concept>
  <concept>
    <code value="20592" />
    <display value="Temporomandibular joints" />
    <designation>
      <language value="fr" />
      <value value="Articulations temporo-mandibulaires" />
    </designation>
  </concept>
  <concept>
    <code value="20593" />
    <display value="Sinus" />
    <designation>
      <language value="fr" />
      <value value="Sinus" />
    </designation>
  </concept>
  <concept>
    <code value="20594" />
    <display value="Trauma or injury" />
    <designation>
      <language value="fr" />
      <value value="Traumatisme ou blessure" />
    </designation>
  </concept>
  <concept>
    <code value="20595" />
    <display value="Eye for foreign body" />
    <designation>
      <language value="fr" />
      <value value="Œil pour corps étranger" />
    </designation>
  </concept>
  <concept>
    <code value="20596" />
    <display value="Shoulder" />
    <designation>
      <language value="fr" />
      <value value="Épaule" />
    </designation>
  </concept>
  <concept>
    <code value="20597" />
    <display value="Clavicle" />
    <designation>
      <language value="fr" />
      <value value="Clavicule" />
    </designation>
  </concept>
  <concept>
    <code value="20598" />
    <display value="Acromioclavicular joints" />
    <designation>
      <language value="fr" />
      <value value="Articulations acromioclaviculaires" />
    </designation>
  </concept>
  <concept>
    <code value="20599" />
    <display value="Scapula" />
    <designation>
      <language value="fr" />
      <value value="Omoplate" />
    </designation>
  </concept>
  <concept>
    <code value="20600" />
    <display value="Humerus" />
    <designation>
      <language value="fr" />
      <value value="Humérus" />
    </designation>
  </concept>
  <concept>
    <code value="20601" />
    <display value="Elbow" />
    <designation>
      <language value="fr" />
      <value value="Coude" />
    </designation>
  </concept>
  <concept>
    <code value="20602" />
    <display value="Forearm" />
    <designation>
      <language value="fr" />
      <value value="Avant-bras" />
    </designation>
  </concept>
  <concept>
    <code value="20603" />
    <display value="Wrist" />
    <designation>
      <language value="fr" />
      <value value="Poignet" />
    </designation>
  </concept>
  <concept>
    <code value="20604" />
    <display value="Scaphoid" />
    <designation>
      <language value="fr" />
      <value value="Scaphoïde" />
    </designation>
  </concept>
  <concept>
    <code value="20605" />
    <display value="Hand" />
    <designation>
      <language value="fr" />
      <value value="Main" />
    </designation>
  </concept>
  <concept>
    <code value="20606" />
    <display value="Finger" />
    <designation>
      <language value="fr" />
      <value value="Doigt" />
    </designation>
  </concept>
  <concept>
    <code value="20607" />
    <display value="Pelvis" />
    <designation>
      <language value="fr" />
      <value value="Bassins" />
    </designation>
  </concept>
  <concept>
    <code value="20608" />
    <display value="Hip" />
    <designation>
      <language value="fr" />
      <value value="Hanche" />
    </designation>
  </concept>
  <concept>
    <code value="20609" />
    <display value="Femur" />
    <designation>
      <language value="fr" />
      <value value="Fémur" />
    </designation>
  </concept>
  <concept>
    <code value="20610" />
    <display value="Knee" />
    <designation>
      <language value="fr" />
      <value value="Genou" />
    </designation>
  </concept>
  <concept>
    <code value="20611" />
    <display value="Patella" />
    <designation>
      <language value="fr" />
      <value value="Rotule" />
    </designation>
  </concept>
  <concept>
    <code value="20612" />
    <display value="Tibia and fibula" />
    <designation>
      <language value="fr" />
      <value value="Tibia et fibula" />
    </designation>
  </concept>
  <concept>
    <code value="20613" />
    <display value="Ankle" />
    <designation>
      <language value="fr" />
      <value value="Cheville" />
    </designation>
  </concept>
  <concept>
    <code value="20614" />
    <display value="Foot" />
    <designation>
      <language value="fr" />
      <value value="Pied" />
    </designation>
  </concept>
  <concept>
    <code value="20615" />
    <display value="Calcaneus" />
    <designation>
      <language value="fr" />
      <value value="Calcanéum" />
    </designation>
  </concept>
  <concept>
    <code value="20616" />
    <display value="Toes" />
    <designation>
      <language value="fr" />
      <value value="Orteils" />
    </designation>
  </concept>
  <concept>
    <code value="20617" />
    <display value="Leg length" />
    <designation>
      <language value="fr" />
      <value value="Longueur de jambe" />
    </designation>
  </concept>
  <concept>
    <code value="20618" />
    <display value="Metabolic" />
    <designation>
      <language value="fr" />
      <value value="Métabolique" />
    </designation>
  </concept>
  <concept>
    <code value="20619" />
    <display value="Metastatic" />
    <designation>
      <language value="fr" />
      <value value="Métastatique" />
    </designation>
  </concept>
  <concept>
    <code value="20620" />
    <display value="Rheumatoid" />
    <designation>
      <language value="fr" />
      <value value="Rhumatoïde" />
    </designation>
  </concept>
  <concept>
    <code value="20621" />
    <display value="Babygram" />
    <designation>
      <language value="fr" />
      <value value="Radiographie du bébé" />
    </designation>
  </concept>
  <concept>
    <code value="20622" />
    <display value="Gastrointestinal tract" />
    <designation>
      <language value="fr" />
      <value value="Tube gastro-intestinal" />
    </designation>
  </concept>
  <concept>
    <code value="20623" />
    <display value="Retrograde urethrogram" />
    <designation>
      <language value="fr" />
      <value value="Uréthrogramme rétrograde" />
    </designation>
  </concept>
  <concept>
    <code value="20624" />
    <display value="Cystourethrogram" />
    <designation>
      <language value="fr" />
      <value value="Cystouréthrogramme" />
    </designation>
  </concept>
  <concept>
    <code value="20625" />
    <display value="Hysterosalpingogram" />
    <designation>
      <language value="fr" />
      <value value="Hystérosalpingogramme" />
    </designation>
  </concept>
  <concept>
    <code value="20626" />
    <display value="Sinogram" />
    <designation>
      <language value="fr" />
      <value value="Sinogramme" />
    </designation>
  </concept>
  <concept>
    <code value="20627" />
    <display value="Musculoskeletal injections" />
    <designation>
      <language value="fr" />
      <value value="Injections musculosquelettiques" />
    </designation>
  </concept>
  <concept>
    <code value="20628" />
    <display value="Modified barium swallow (Video fluoroscope swallowing exam)" />
    <designation>
      <language value="fr" />
      <value value="Déglutition au baryum modifiée (Examen de déglutition par fluoroscope vidéo)" />
    </designation>
  </concept>
  <concept>
    <code value="20629" />
    <display value="Barium swallow" />
    <designation>
      <language value="fr" />
      <value value="Déglutition au baryum" />
    </designation>
  </concept>
  <concept>
    <code value="20630" />
    <display value="Upper GI series (Esophagus, stomach and duodenum)" />
    <designation>
      <language value="fr" />
      <value value="Série GI supérieure (Œsophage, estomac et duodénum)" />
    </designation>
  </concept>
  <concept>
    <code value="20631" />
    <display value="Small bowel follow through" />
    <designation>
      <language value="fr" />
      <value value="Suivi de l'intestin grêle" />
    </designation>
  </concept>
  <concept>
    <code value="20632" />
    <display value="Barium enema" />
    <designation>
      <language value="fr" />
      <value value="Lavement baryté" />
    </designation>
  </concept>
  <concept>
    <code value="20633" />
    <display value="Stress" />
    <designation>
      <language value="fr" />
      <value value="Stress" />
    </designation>
  </concept>
  <concept>
    <code value="20634" />
    <display value="Voiding" />
    <designation>
      <language value="fr" />
      <value value="Miction" />
    </designation>
  </concept>
  <concept>
    <code value="20635" />
    <display value="Abdomen" />
    <designation>
      <language value="fr" />
      <value value="Abdomen" />
    </designation>
  </concept>
  <concept>
    <code value="20636" />
    <display value="Pelvis" />
    <designation>
      <language value="fr" />
      <value value="Bassins" />
    </designation>
  </concept>
  <concept>
    <code value="20637" />
    <display value="Obstetrical" />
    <designation>
      <language value="fr" />
      <value value="Obstétrical" />
    </designation>
  </concept>
  <concept>
    <code value="20638" />
    <display value="Neonatal and Paediatric" />
    <designation>
      <language value="fr" />
      <value value="Néonatal et pédiatrique" />
    </designation>
  </concept>
  <concept>
    <code value="20639" />
    <display value="Musculoskeletal" />
    <designation>
      <language value="fr" />
      <value value="Musculosquelettique" />
    </designation>
  </concept>
  <concept>
    <code value="20640" />
    <display value="Vascular" />
    <designation>
      <language value="fr" />
      <value value="Vasculaire" />
    </designation>
  </concept>
  <concept>
    <code value="20641" />
    <display value="Head and Neck" />
    <designation>
      <language value="fr" />
      <value value="Tête et cou" />
    </designation>
  </concept>
  <concept>
    <code value="20642" />
    <display value="Breast and Axilla" />
    <designation>
      <language value="fr" />
      <value value="Sein et aisselle" />
    </designation>
  </concept>
  <concept>
    <code value="20643" />
    <display value="Complete abdomen" />
    <designation>
      <language value="fr" />
      <value value="Abdomen complet" />
    </designation>
  </concept>
  <concept>
    <code value="20644" />
    <display value="Appendix" />
    <designation>
      <language value="fr" />
      <value value="Appendice" />
    </designation>
  </concept>
  <concept>
    <code value="20645" />
    <display value="Gallbladder" />
    <designation>
      <language value="fr" />
      <value value="Vésicule biliaire" />
    </designation>
  </concept>
  <concept>
    <code value="20646" />
    <display value="Kidney Ureters Bladder" />
    <designation>
      <language value="fr" />
      <value value="Rein Uretères Vessie" />
    </designation>
  </concept>
  <concept>
    <code value="20647" />
    <display value="Liver" />
    <designation>
      <language value="fr" />
      <value value="Foie" />
    </designation>
  </concept>
  <concept>
    <code value="20648" />
    <display value="Liver elastography" />
    <designation>
      <language value="fr" />
      <value value="Élastographie du foie" />
    </designation>
  </concept>
  <concept>
    <code value="20649" />
    <display value="Pancreas" />
    <designation>
      <language value="fr" />
      <value value="Pancréas" />
    </designation>
  </concept>
  <concept>
    <code value="20650" />
    <display value="Portal hypertension" />
    <designation>
      <language value="fr" />
      <value value="Hypertension portale" />
    </designation>
  </concept>
  <concept>
    <code value="20651" />
    <display value="Renal" />
    <designation>
      <language value="fr" />
      <value value="Rénal" />
    </designation>
  </concept>
  <concept>
    <code value="20652" />
    <display value="Right upper quadrant" />
    <designation>
      <language value="fr" />
      <value value="Quadrant supérieur droit" />
    </designation>
  </concept>
  <concept>
    <code value="20653" />
    <display value="Spleen" />
    <designation>
      <language value="fr" />
      <value value="Rate" />
    </designation>
  </concept>
  <concept>
    <code value="20654" />
    <display value="Abdomen contrast" />
    <designation>
      <language value="fr" />
      <value value="Abdomen avec contraste" />
    </designation>
  </concept>
  <concept>
    <code value="20655" />
    <display value="Abdominal wall" />
    <designation>
      <language value="fr" />
      <value value="Paroi abdominale" />
    </designation>
  </concept>
  <concept>
    <code value="20656" />
    <display value="Complete pelvis" />
    <designation>
      <language value="fr" />
      <value value="Bassins complet" />
    </designation>
  </concept>
  <concept>
    <code value="20657" />
    <display value="Pelvis transabdominal" />
    <designation>
      <language value="fr" />
      <value value="Bassins transabdominal" />
    </designation>
  </concept>
  <concept>
    <code value="20658" />
    <display value="Female pelvis (transvaginal)" />
    <designation>
      <language value="fr" />
      <value value="Bassins féminin (transvaginal)" />
    </designation>
  </concept>
  <concept>
    <code value="20659" />
    <display value="Follicular monitoring" />
    <designation>
      <language value="fr" />
      <value value="Surveillance folliculaire" />
    </designation>
  </concept>
  <concept>
    <code value="20660" />
    <display value="Limited non-pregnancy (for IUD insertion placement check)" />
    <designation>
      <language value="fr" />
      <value value="Non-grossesse limitée (pour vérification de l'insertion du DIU)" />
    </designation>
  </concept>
  <concept>
    <code value="20661" />
    <display value="Saline Infusion Sonohysterography" />
    <designation>
      <language value="fr" />
      <value value="Sonohystérographie par perfusion de sérum physiologique" />
    </designation>
  </concept>
  <concept>
    <code value="20662" />
    <display value="Male pelvis (Transrectal)" />
    <designation>
      <language value="fr" />
      <value value="Bassins masculin (transrectal)" />
    </designation>
  </concept>
  <concept>
    <code value="20663" />
    <display value="Prostate" />
    <designation>
      <language value="fr" />
      <value value="Prostate" />
    </designation>
  </concept>
  <concept>
    <code value="20664" />
    <display value="Penile" />
    <designation>
      <language value="fr" />
      <value value="Pénien" />
    </designation>
  </concept>
  <concept>
    <code value="20665" />
    <display value="Testicles/Scrotum" />
    <designation>
      <language value="fr" />
      <value value="Testicules/Scrotum" />
    </designation>
  </concept>
  <concept>
    <code value="20666" />
    <display value="Bladder" />
    <designation>
      <language value="fr" />
      <value value="Vessie" />
    </designation>
  </concept>
  <concept>
    <code value="20667" />
    <display value="Groin" />
    <designation>
      <language value="fr" />
      <value value="Aine" />
    </designation>
  </concept>
  <concept>
    <code value="20668" />
    <display value="Singleton" />
    <designation>
      <language value="fr" />
      <value value="Grossesse unique" />
    </designation>
  </concept>
  <concept>
    <code value="20669" />
    <display value="Twins" />
    <designation>
      <language value="fr" />
      <value value="Jumeaux" />
    </designation>
  </concept>
  <concept>
    <code value="20670" />
    <display value="Triplets" />
    <designation>
      <language value="fr" />
      <value value="Triplés" />
    </designation>
  </concept>
  <concept>
    <code value="20671" />
    <display value="Unknown" />
    <designation>
      <language value="fr" />
      <value value="Inconnu" />
    </designation>
  </concept>
  <concept>
    <code value="20672" />
    <display value="Dating (&lt;16 weeks)" />
    <designation>
      <language value="fr" />
      <value value="Datation (&lt;16 semaines)" />
    </designation>
  </concept>
  <concept>
    <code value="20673" />
    <display value="Prenatal screening (NT/eFTS) 11-14 weeks" />
    <designation>
      <language value="fr" />
      <value value="Dépistage prénatal (NT/eFTS) 11-14 semaines" />
    </designation>
  </concept>
  <concept>
    <code value="20674" />
    <display value="Anatomy (20 week scan)" />
    <designation>
      <language value="fr" />
      <value value="Anatomie (échographie de 20 semaines)" />
    </designation>
  </concept>
  <concept>
    <code value="20675" />
    <display value="2nd or 3rd trimester scan" />
    <designation>
      <language value="fr" />
      <value value="Échographie du 2e ou 3e trimestre" />
    </designation>
  </concept>
  <concept>
    <code value="20676" />
    <display value="Biophysical profile" />
    <designation>
      <language value="fr" />
      <value value="Profil bio-physique" />
    </designation>
  </concept>
  <concept>
    <code value="20677" />
    <display value="Growth" />
    <designation>
      <language value="fr" />
      <value value="Croissance" />
    </designation>
  </concept>
  <concept>
    <code value="20678" />
    <display value="Cervical length" />
    <designation>
      <language value="fr" />
      <value value="Longueur cervicale" />
    </designation>
  </concept>
  <concept>
    <code value="20745" />
    <display value="With transvaginal" />
    <designation>
      <language value="fr" />
      <value value="Avec transvaginal" />
    </designation>
  </concept>
  <concept>
    <code value="20679" />
    <display value="Multi-gestational study" />
    <designation>
      <language value="fr" />
      <value value="Étude multi-gestationnelle" />
    </designation>
  </concept>
  <concept>
    <code value="20680" />
    <display value="High risk pregnancy" />
    <designation>
      <language value="fr" />
      <value value="Grossesse à haut risque" />
    </designation>
  </concept>
  <concept>
    <code value="20681" />
    <display value="Uterine artery doppler studies" />
    <designation>
      <language value="fr" />
      <value value="Études Doppler de l'artère utérine" />
    </designation>
  </concept>
  <concept>
    <code value="20682" />
    <display value="Umbilical artery doppler studies" />
    <designation>
      <language value="fr" />
      <value value="Études Doppler de l'artère ombilicale" />
    </designation>
  </concept>
  <concept>
    <code value="20683" />
    <display value="Fetal doppler" />
    <designation>
      <language value="fr" />
      <value value="Doppler fœtal" />
    </designation>
  </concept>
  <concept>
    <code value="20684" />
    <display value="Report sex" />
    <designation>
      <language value="fr" />
      <value value="Indiquer le sexe" />
    </designation>
  </concept>
  <concept>
    <code value="20685" />
    <display value="1st Trimester" />
  </concept>
  <concept>
    <code value="20686" />
    <display value="2nd and 3rd Trimester" />
  </concept>
  <concept>
    <code value="20687" />
    <display value="Pylorus" />
  </concept>
  <concept>
    <code value="20688" />
    <display value="Spine" />
  </concept>
  <concept>
    <code value="20689" />
    <display value="Brain" />
  </concept>
  <concept>
    <code value="20690" />
    <display value="Hips" />
  </concept>
  <concept>
    <code value="20691" />
    <display value="Pylorus and Hypertrophic Pyloric Stenosis" />
  </concept>
  <concept>
    <code value="20692" />
    <display value="Bowel" />
  </concept>
  <concept>
    <code value="20693" />
    <display value="Foot" />
  </concept>
  <concept>
    <code value="20694" />
    <display value="Plantar fascia" />
  </concept>
  <concept>
    <code value="20695" />
    <display value="Ankle" />
  </concept>
  <concept>
    <code value="20696" />
    <display value="Achilles" />
  </concept>
  <concept>
    <code value="20697" />
    <display value="Calf/Lower leg/Gastrocnemius" />
  </concept>
  <concept>
    <code value="20698" />
    <display value="Knee" />
  </concept>
  <concept>
    <code value="20699" />
    <display value="Patellar tendon" />
  </concept>
  <concept>
    <code value="20700" />
    <display value="Popliteal fossa" />
  </concept>
  <concept>
    <code value="20701" />
    <display value="Quadriceps tendon" />
  </concept>
  <concept>
    <code value="20702" />
    <display value="Thigh/Hamstrings" />
  </concept>
  <concept>
    <code value="20703" />
    <display value="Hip" />
  </concept>
  <concept>
    <code value="20704" />
    <display value="Gluteal region" />
  </concept>
  <concept>
    <code value="20705" />
    <display value="Hand" />
  </concept>
  <concept>
    <code value="20706" />
    <display value="Wrist" />
  </concept>
  <concept>
    <code value="20707" />
    <display value="Carpal tunnel" />
  </concept>
  <concept>
    <code value="20708" />
    <display value="Forearm" />
  </concept>
  <concept>
    <code value="20709" />
    <display value="Elbow" />
  </concept>
  <concept>
    <code value="20710" />
    <display value="Biceps" />
  </concept>
  <concept>
    <code value="20711" />
    <display value="Triceps" />
  </concept>
  <concept>
    <code value="20712" />
    <display value="Shoulders" />
  </concept>
  <concept>
    <code value="20713" />
    <display value="Rotator cuff" />
  </concept>
  <concept>
    <code value="20714" />
    <display value="Toe(s)" />
  </concept>
  <concept>
    <code value="20715" />
    <display value="Finger(s)" />
  </concept>
  <concept>
    <code value="20716" />
    <display value="Palpable masses" />
  </concept>
  <concept>
    <code value="20717" />
    <display value="Foreign body" />
  </concept>
  <concept>
    <code value="20718" />
    <display value="Upper extremity arterial" />
  </concept>
  <concept>
    <code value="20719" />
    <display value="Upper extremity venous" />
  </concept>
  <concept>
    <code value="20720" />
    <display value="Lower extremity arterial" />
  </concept>
  <concept>
    <code value="20721" />
    <display value="Lower extremity venous thrombosis" />
  </concept>
  <concept>
    <code value="20722" />
    <display value="Lower extremity venous reflux" />
  </concept>
  <concept>
    <code value="20723" />
    <display value="Abdominal aortic aneurysm screen" />
  </concept>
  <concept>
    <code value="20724" />
    <display value="Ankle brachial index" />
  </concept>
  <concept>
    <code value="20725" />
    <display value="Arterial venous fistula" />
  </concept>
  <concept>
    <code value="20726" />
    <display value="Carotid" />
  </concept>
  <concept>
    <code value="20727" />
    <display value="Inferior vena cava" />
  </concept>
  <concept>
    <code value="20728" />
    <display value="Portal vein" />
  </concept>
  <concept>
    <code value="20729" />
    <display value="Renal arteries" />
  </concept>
  <concept>
    <code value="20730" />
    <display value="Superior mesenteric artery (SMA)" />
  </concept>
  <concept>
    <code value="20731" />
    <display value="Temporal arteries" />
  </concept>
  <concept>
    <code value="20732" />
    <display value="Venous mapping" />
  </concept>
  <concept>
    <code value="20733" />
    <display value="Neck/Salivary gland" />
  </concept>
  <concept>
    <code value="20734" />
    <display value="Lymph nodes" />
  </concept>
  <concept>
    <code value="20735" />
    <display value="Thyroid" />
  </concept>
  <concept>
    <code value="20736" />
    <display value="Breast" />
  </concept>
  <concept>
    <code value="20737" />
    <display value="Axilla" />
  </concept>
  <concept>
    <code value="20738" />
    <display value="Chest" />
  </concept>
  <concept>
    <code value="20739" />
    <display value="Chest wall (mass)" />
  </concept>
  <concept>
    <code value="20740" />
    <display value="Soft tissue" />
  </concept>
  <concept>
    <code value="20741" />
    <display value="Baseline" />
  </concept>
  <concept>
    <code value="20742" />
    <display value="Low Risk" />
  </concept>
  <concept>
    <code value="20743" />
    <display value="High Risk" />
  </concept>
  <concept>
    <code value="20748" />
    <display value="Breast" />
  </concept>
  <concept>
    <code value="20749" />
    <display value="Burns and Sequelae" />
  </concept>
  <concept>
    <code value="20750" />
    <display value="Congenital Conditions" />
  </concept>
  <concept>
    <code value="20751" />
    <display value="Facial Trauma and Reconstruction" />
  </concept>
  <concept>
    <code value="20752" />
    <display value="Gender-Affirming Surgery" />
  </concept>
  <concept>
    <code value="20753" />
    <display value="Hand and Upper Limb" />
  </concept>
  <concept>
    <code value="20754" />
    <display value="Peripheral Nerve, Carpal Tunnel Syndrome, and Brachial Plexus" />
  </concept>
  <concept>
    <code value="20755" />
    <display value="Skin Lesions and Skin Cancer" />
  </concept>
  <concept>
    <code value="20756" />
    <display value="Soft Tissue Tumours" />
  </concept>
  <concept>
    <code value="20757" />
    <display value="Wound - Acute" />
  </concept>
  <concept>
    <code value="20758" />
    <display value="Wound - Chronic / Complex" />
  </concept>
  <concept>
    <code value="20759" />
    <display value="Breast Reduction" />
  </concept>
  <concept>
    <code value="20760" />
    <display value="Gynecomastia" />
  </concept>
  <concept>
    <code value="20761" />
    <display value="Post-Mastectomy Reconstruction" />
  </concept>
  <concept>
    <code value="20762" />
    <display value="Revision of Prior Breast-Surgery" />
  </concept>
  <concept>
    <code value="20763" />
    <display value="Acute Burns" />
  </concept>
  <concept>
    <code value="20764" />
    <display value="Burn Scar Contracture" />
  </concept>
  <concept>
    <code value="20765" />
    <display value="Non-Healing Burn Wounds" />
  </concept>
  <concept>
    <code value="20766" />
    <display value="Scar Revision" />
  </concept>
  <concept>
    <code value="20767" />
    <display value="Date of Injury / Onset" />
  </concept>
  <concept>
    <code value="20768" />
    <display value="Cleft Lip / Palate" />
  </concept>
  <concept>
    <code value="20769" />
    <display value="Craniofacial Anomalies" />
  </concept>
  <concept>
    <code value="20770" />
    <display value="Ear Anomalies" />
  </concept>
  <concept>
    <code value="20771" />
    <display value="Hand Anomalies" />
  </concept>
  <concept>
    <code value="20772" />
    <display value="Vascular Anomaly / Malformation" />
  </concept>
  <concept>
    <code value="20773" />
    <display value="Acute Facial Fractures" />
  </concept>
  <concept>
    <code value="20774" />
    <display value="Acute Soft Tissue Injuries" />
  </concept>
  <concept>
    <code value="20775" />
    <display value="Reconstruction After Trauma" />
  </concept>
  <concept>
    <code value="20776" />
    <display value="Chest (Top) Surgery" />
  </concept>
  <concept>
    <code value="20777" />
    <display value="Facial Gender-Affirming Surgery" />
  </concept>
  <concept>
    <code value="20778" />
    <display value="Genital (Bottom) Surgery" />
  </concept>
  <concept>
    <code value="20780" />
    <display value="Fracture - Acute" />
  </concept>
  <concept>
    <code value="20781" />
    <display value="Hand Osteoarthritis (with deformity/pain/loss of function)" />
  </concept>
  <concept>
    <code value="20782" />
    <display value="Malunion / Non-union of Fractures" />
  </concept>
  <concept>
    <code value="20783" />
    <display value="Tendon Injury - Acute" />
  </concept>
  <concept>
    <code value="20785" />
    <display value="Brachial Plexus - Congenital Condition" />
  </concept>
  <concept>
    <code value="20786" />
    <display value="Brachial Plexus - Traumatic Injury" />
  </concept>
  <concept>
    <code value="20788" />
    <display value="Cubital Tunnel Syndrome" />
  </concept>
  <concept>
    <code value="20789" />
    <display value="Peripheral Nerve Injury" />
  </concept>
  <concept>
    <code value="20790" />
    <display value="Peripheral Nerve Tumour" />
  </concept>
  <concept>
    <code value="20791" />
    <display value="Basal Cell Carcinoma" />
  </concept>
  <concept>
    <code value="20792" />
    <display value="Squamous Cell Carcinoma" />
  </concept>
  <concept>
    <code value="20794" />
    <display value="Benign or Symptomatic Lesion(s) (e.g. epidermal cysts, superficial lipomas)" />
  </concept>
  <concept>
    <code value="20796" />
    <display value="Post-Cancer Reconstruction" />
  </concept>
  <concept>
    <code value="20798" />
    <display value="Soft Tissue Sarcoma" />
  </concept>
  <concept>
    <code value="20800" />
    <display value="Complex Wound (e.g., mixed etiology, non-healing, exposed structures)" />
  </concept>
  <concept>
    <code value="20801" />
    <display value="Diabetic / Ischemic Foot Ulcer" />
  </concept>
  <concept>
    <code value="20802" />
    <display value="Pressure Injury" />
  </concept>
  <concept>
    <code value="20803" />
    <display value="Surgical Wound - Non-Healing" />
  </concept>
  <concept>
    <code value="20804" />
    <display value="Venous Leg Ulcer" />
  </concept>
  <concept>
    <code value="20805" />
    <display value="Anxiety or Panic Symptoms" />
  </concept>
  <concept>
    <code value="20806" />
    <display value="Attention, Focus or Cognitive Processing Problems" />
  </concept>
  <concept>
    <code value="20807" />
    <display value="Behavioural Addictions (e.g., gambling, gaming, internet use, sexual)" />
  </concept>
  <concept>
    <code value="20808" />
    <display value="Bipolar / Mania Symptoms" />
  </concept>
  <concept>
    <code value="20809" />
    <display value="Dementia-Related Behaviours" />
  </concept>
  <concept>
    <code value="20810" />
    <display value="Depression Symptoms or Low Mood" />
  </concept>
  <concept>
    <code value="20811" />
    <display value="Eating Concerns (e.g., restricted or binge eating)" />
  </concept>
  <concept>
    <code value="20812" />
    <display value="Emotional Dysregulation (e.g., anger, aggression, mood swings)" />
  </concept>
  <concept>
    <code value="20813" />
    <display value="Hyperactivity or Impulsivity" />
  </concept>
  <concept>
    <code value="20814" />
    <display value="Intellectual Disability" />
  </concept>
  <concept>
    <code value="20815" />
    <display value="Memory Concerns" />
  </concept>
  <concept>
    <code value="20816" />
    <display value="Neurodevelopmental Concerns (e.g., autism-spectrum, ADHD)" />
  </concept>
  <concept>
    <code value="20817" />
    <display value="Obsessions or Compulsions" />
  </concept>
  <concept>
    <code value="20818" />
    <display value="Personality-Related Concerns (e.g., unstable relationships, chronic conflict with others)" />
  </concept>
  <concept>
    <code value="20819" />
    <display value="Psychotic Symptoms (e.g., hallucinations, delusions, etc.)" />
  </concept>
  <concept>
    <code value="20820" />
    <display value="Substance Use Concerns" />
  </concept>
  <concept>
    <code value="20821" />
    <display value="Trauma-Related Symptoms / PTSD (e.g., hypervigilance, flashbacks)" />
  </concept>
  <concept>
    <code value="20822" />
    <display value="Height (cm)" />
  </concept>
  <concept>
    <code value="20823" />
    <display value="Weight (kg)" />
  </concept>
  <concept>
    <code value="20824" />
    <display value="BMI" />
  </concept>
  <concept>
    <code value="20825" />
    <display value="Homicidal Ideation / Threats" />
  </concept>
  <concept>
    <code value="20826" />
    <display value="Self-Harm Behaviours" />
  </concept>
  <concept>
    <code value="20827" />
    <display value="Suicidal Ideation or Attempt" />
  </concept>
  <concept>
    <code value="20828" />
    <display value="Violence or Aggression" />
  </concept>
  <concept>
    <code value="20829" />
    <display value="Housing Instability" />
  </concept>
  <concept>
    <code value="20830" />
    <display value="Legal Involvement / History" />
  </concept>
  <concept>
    <code value="20832" />
    <display value="Behavioural Addictions (e.g., gambling, internet use, gaming, sexual)" />
  </concept>
  <concept>
    <code value="20836" />
    <display value="Difficulty coping with life stressors (e.g. grief, loss)" />
  </concept>
  <concept>
    <code value="20841" />
    <display value="Psychotic Symptoms" />
  </concept>
  <concept>
    <code value="20844" />
    <display value="Current Weight (kgs)" />
  </concept>
  <concept>
    <code value="20845" />
    <display value="Current Weight (lbs)" />
  </concept>
  <concept>
    <code value="20846" />
    <display value="Current Height (cm)" />
  </concept>
  <concept>
    <code value="20848" />
    <display value="Blood Pressure" />
  </concept>
  <concept>
    <code value="20849" />
    <display value="Heart Rate" />
  </concept>
  <concept>
    <code value="20850" />
    <display value="Date of LMP" />
  </concept>
  <concept>
    <code value="20851" />
    <display value="Food Intake Restrictions" />
  </concept>
  <concept>
    <code value="20852" />
    <display value="Binge Eating" />
  </concept>
  <concept>
    <code value="20853" />
    <display value="Induced Vomiting" />
  </concept>
  <concept>
    <code value="20854" />
    <display value="Laxative Use" />
  </concept>
  <concept>
    <code value="20855" />
    <display value="Exercise Quantity (per week)" />
  </concept>
  <concept>
    <code value="20856" />
    <display value="Chewing and Spitting" />
  </concept>
  <concept>
    <code value="20857" />
    <display value="Diet Medications" />
  </concept>
  <concept>
    <code value="20858" />
    <display value="First Episode Psychosis" />
  </concept>
  <concept>
    <code value="20859" />
    <display value="Case Management" />
  </concept>
  <concept>
    <code value="20860" />
    <display value="Counselling / Psychotherapy Services" />
  </concept>
  <concept>
    <code value="20861" />
    <display value="Psychiatric Consultation" />
  </concept>
  <concept>
    <code value="20862" />
    <display value="Diagnostic Clarification" />
  </concept>
  <concept>
    <code value="20863" />
    <display value="Interventional Psychiatry" />
  </concept>
  <concept>
    <code value="20864" />
    <display value="Medication / Treatment Recommendations" />
  </concept>
  <concept>
    <code value="20865" />
    <display value="Electroconvulsive therapy (ECT)" />
  </concept>
  <concept>
    <code value="20866" />
    <display value="Repetitive Transcranial Magnetic Stimulation (rTMS)" />
  </concept>
  <concept>
    <code value="20867" />
    <display value="Family Support Services" />
  </concept>
  <concept>
    <code value="20868" />
    <display value="Peer Support Services" />
  </concept>
  <concept>
    <code value="20869" />
    <display value="Supportive Housing" />
  </concept>
  <concept>
    <code value="20870" />
    <display value="Bed-Based Addiction Treatment (formerly known as Residential Addiction Services)" />
  </concept>
  <concept>
    <code value="20871" />
    <display value="Substance Use / Addiction Treatment" />
  </concept>
  <concept>
    <code value="20872" />
    <display value="Stabilization on Opioid Agonist Therapy" />
  </concept>
  <concept>
    <code value="20873" />
    <display value="Withdrawal Management" />
  </concept>
  <concept>
    <code value="20874" />
    <display value="Court Support" />
  </concept>
  <concept>
    <code value="20875" />
    <display value="Possible Safety Concern to Others (e.g. aggression, homicidal threats or ideation)" />
  </concept>
  <concept>
    <code value="20879" />
    <display value="Legal Involvement / Court Orders (e.g. current charges, probation, parole, CTO/ORB conditions)" />
  </concept>
  <concept>
    <code value="20880" />
    <display value="Bone and Joint Infections" />
  </concept>
  <concept>
    <code value="20881" />
    <display value="Clostridioides difficile (C. diff)" />
  </concept>
  <concept>
    <code value="20882" />
    <display value="Endocarditis" />
  </concept>
  <concept>
    <code value="20883" />
    <display value="Fever of Unknown Origin (FUO)" />
  </concept>
  <concept>
    <code value="20884" />
    <display value="HIV" />
  </concept>
  <concept>
    <code value="20885" />
    <display value="Intra-Abdominal or Pelvic Infections" />
  </concept>
  <concept>
    <code value="20886" />
    <display value="Lung Infections" />
  </concept>
  <concept>
    <code value="20887" />
    <display value="Sexually Transmitted Infections (STIs)" />
  </concept>
  <concept>
    <code value="20888" />
    <display value="Skin and Soft Tissue Infections (SSTIs)" />
  </concept>
  <concept>
    <code value="20889" />
    <display value="Tick-borne Infections" />
  </concept>
  <concept>
    <code value="20890" />
    <display value="Tropical and Parasitic Diseases" />
  </concept>
  <concept>
    <code value="20891" />
    <display value="Tuberculosis (TB)" />
  </concept>
  <concept>
    <code value="20892" />
    <display value="Urinary Tract Infection (UTIs)" />
  </concept>
  <concept>
    <code value="20893" />
    <display value="Viral Hepatitis" />
  </concept>
  <concept>
    <code value="20894" />
    <display value="Osteomyelitis" />
  </concept>
  <concept>
    <code value="20895" />
    <display value="Prosthetic Joint Infection" />
  </concept>
  <concept>
    <code value="20896" />
    <display value="Septic Arthritis" />
  </concept>
  <concept>
    <code value="20897" />
    <display value="Spinal Infections" />
  </concept>
  <concept>
    <code value="20898" />
    <display value="HIV - New Diagnosis" />
  </concept>
  <concept>
    <code value="20899" />
    <display value="HIV - Ongoing Care" />
  </concept>
  <concept>
    <code value="20900" />
    <display value="PrEP (Pre-Exposure Prophylaxis)" />
  </concept>
  <concept>
    <code value="20901" />
    <display value="PEP (Post-Exposure Prophylaxis)" />
  </concept>
  <concept>
    <code value="20903" />
    <display value="Cellulitis" />
  </concept>
  <concept>
    <code value="20904" />
    <display value="Diabetic Foot Infection" />
  </concept>
  <concept>
    <code value="20905" />
    <display value="Malaria" />
  </concept>
  <concept>
    <code value="20906" />
    <display value="Active TB - Confirmed" />
  </concept>
  <concept>
    <code value="20907" />
    <display value="Active TB -� Suspected" />
  </concept>
  <concept>
    <code value="20908" />
    <display value="Latent TB Infection" />
  </concept>
  <concept>
    <code value="20909" />
    <display value="Active drug and/or alcohol addiction" />
  </concept>
  <concept>
    <code value="20910" />
    <display value="Active treatment for a major/life-threatening cancer (e.g. chemotherapy, radiation)" />
  </concept>
  <concept>
    <code value="20911" />
    <display value="Significant psychiatric illness that is inadequately treated" />
  </concept>
  <concept>
    <code value="20912" />
    <display value="Patient &gt;18 years old" />
  </concept>
  <concept>
    <code value="20913" />
    <display value="Patient has an Ontario Health Card OR is a resident of Ontario and meets one of the following�" />
  </concept>
  <concept>
    <code value="20915" />
    <display value="Weight (kgs)" />
  </concept>
  <concept>
    <code value="20916" />
    <display value="Height (ft)" />
  </concept>
  <concept>
    <code value="20917" />
    <display value="Height (in)" />
  </concept>
  <concept>
    <code value="20918" />
    <display value="Weight (lbs)" />
  </concept>
  <concept>
    <code value="20920" />
    <display value="Previously had bariatric surgery" />
  </concept>
  <concept>
    <code value="20921" />
    <display value="Surgical complications" />
  </concept>
  <concept>
    <code value="20922" />
    <display value="Weight regain (&gt;15% increase)" />
  </concept>
  <concept>
    <code value="20923" />
    <display value="Idiopathic intracranial hypertension" />
  </concept>
  <concept>
    <code value="20924" />
    <display value="Coronary heart disease" />
  </concept>
  <concept>
    <code value="20925" />
    <display value="Type 2 diabetes" />
  </concept>
  <concept>
    <code value="20927" />
    <display value="Diagnosed sleep apnea" />
  </concept>
  <concept>
    <code value="20929" />
    <display value="Renal disease" />
  </concept>
  <concept>
    <code value="20930" />
    <display value="Surgical Program" />
  </concept>
  <concept>
    <code value="20931" />
    <display value="Medical Program" />
  </concept>
  <concept>
    <code value="20932" />
    <display value="Pilot Metabolic Surgical Program at St. Joseph�s Healthcare Hamilton" />
  </concept>
  <concept>
    <code value="20933" />
    <display value="Optometrist / Ophthalmologist" />
  </concept>
  <concept>
    <code value="20934" />
    <display value="Primary Care" />
  </concept>
  <concept>
    <code value="20935" />
    <display value="Clinical Optometry/Ophthalmology Report attached" />
  </concept>
  <concept>
    <code value="20936" />
    <display value="Right Eye (OD)" />
  </concept>
  <concept>
    <code value="20937" />
    <display value="Left Eye (OS)" />
  </concept>
  <concept>
    <code value="20938" />
    <display value="Both Eyes (OU)" />
  </concept>
  <concept>
    <code value="20939" />
    <display value="Optometry / Ophthalmology report attached including Best Corrected Visual Acuity (BCVA) and Past Ocular History" />
  </concept>
  <concept>
    <code value="20940" />
    <display value="Right Eye" />
  </concept>
  <concept>
    <code value="20941" />
    <display value="Right Eye BCVA 20/" />
  </concept>
  <concept>
    <code value="20942" />
    <display value="Left Eye" />
  </concept>
  <concept>
    <code value="20943" />
    <display value="Left Eye BCVA 20/" />
  </concept>
  <concept>
    <code value="20944" />
    <display value="History of Ocular Pathologies" />
  </concept>
  <concept>
    <code value="20945" />
    <display value="History of Diabetes" />
  </concept>
  <concept>
    <code value="20946" />
    <display value="Right Eye (mmHg)" />
  </concept>
  <concept>
    <code value="20947" />
    <display value="Left Eye (mmHg)" />
  </concept>
  <concept>
    <code value="20948" />
    <display value="Does the patient wear contact lenses?" />
  </concept>
  <concept>
    <code value="20949" />
    <display value="Soft" />
  </concept>
  <concept>
    <code value="20950" />
    <display value="Rigid Gas Permeable" />
  </concept>
  <concept>
    <code value="20951" />
    <display value="Does the patient wear prism in their spectacles?" />
  </concept>
  <concept>
    <code value="20952" />
    <display value="Right Eye (prism)" />
  </concept>
  <concept>
    <code value="20953" />
    <display value="Left Eye (prism)" />
  </concept>
  <concept>
    <code value="20954" />
    <display value="Has the patient had previous corneal refractive surgery?" />
  </concept>
  <concept>
    <code value="20955" />
    <display value="LASIK" />
  </concept>
  <concept>
    <code value="20956" />
    <display value="PRK" />
  </concept>
  <concept>
    <code value="20957" />
    <display value="RK" />
  </concept>
  <concept>
    <code value="20958" />
    <display value="Has the patient had previous eye surgery or laser treatment?" />
  </concept>
  <concept>
    <code value="20962" />
    <display value="Adrenal Gland Disorders" />
  </concept>
  <concept>
    <code value="20963" />
    <display value="Diabetes" />
  </concept>
  <concept>
    <code value="20964" />
    <display value="Dyslipidemia" />
  </concept>
  <concept>
    <code value="20965" />
    <display value="Male Hypogonadism" />
  </concept>
  <concept>
    <code value="20966" />
    <display value="Menopause" />
  </concept>
  <concept>
    <code value="20967" />
    <display value="Oligomenorrhea / Amenorrhea" />
  </concept>
  <concept>
    <code value="20968" />
    <display value="Osteoporosis" />
  </concept>
  <concept>
    <code value="20969" />
    <display value="Parathyroid or Calcium Disorders" />
  </concept>
  <concept>
    <code value="20970" />
    <display value="Pituitary Gland Disorders" />
  </concept>
  <concept>
    <code value="20972" />
    <display value="Thyroid Disorders" />
  </concept>
  <concept>
    <code value="20973" />
    <display value="Transgender (Gender Affirming Hormone Therapy)" />
  </concept>
  <concept>
    <code value="20974" />
    <display value="Weight Management / Metabolic Disorders" />
  </concept>
  <concept>
    <code value="20975" />
    <display value="Type 1 Diabetes" />
  </concept>
  <concept>
    <code value="20978" />
    <display value="New" />
  </concept>
  <concept>
    <code value="20979" />
    <display value="&lt;=6 months ago" />
  </concept>
  <concept>
    <code value="20980" />
    <display value="&gt; 6 months ago" />
  </concept>
  <concept>
    <code value="20977" />
    <display value="Patient on insulin" />
  </concept>
  <concept>
    <code value="20981" />
    <display value="Chemotherapy - current or planned" />
  </concept>
  <concept>
    <code value="20982" />
    <display value="Diabetic Ketoacidosis - recent hospitalization" />
  </concept>
  <concept>
    <code value="20983" />
    <display value="Foot ulcer(s) - active or recurring" />
  </concept>
  <concept>
    <code value="20984" />
    <display value="Glucocorticoids - high doses with recent or anticipated initiation" />
  </concept>
  <concept>
    <code value="20985" />
    <display value="HbA1c &gt;10%" />
  </concept>
  <concept>
    <code value="20986" />
    <display value="Hypoglycemia - severe and recent episode requiring assistance" />
  </concept>
  <concept>
    <code value="20987" />
    <display value="Myocardial infarction or Stroke - recent event with inadequate control" />
  </concept>
  <concept>
    <code value="20988" />
    <display value="Optimization required prior to procedure/surgery - Urgent" />
  </concept>
  <concept>
    <code value="20989" />
    <display value="Transplant within last 6 months" />
  </concept>
  <concept>
    <code value="20990" />
    <display value="HbA1C" />
  </concept>
  <concept>
    <code value="20991" />
    <display value="Triglycerides &gt; 10 mmol/L" />
  </concept>
  <concept>
    <code value="20992" />
    <display value="Atypical femur fracture" />
  </concept>
  <concept>
    <code value="20993" />
    <display value="Fragility fracture - within last year" />
  </concept>
  <concept>
    <code value="20994" />
    <display value="Glucocorticoids - Currently on prolonged high-dose" />
  </concept>
  <concept>
    <code value="20995" />
    <display value="Glucocorticoids - Planned start of prolonged high-dose" />
  </concept>
  <concept>
    <code value="20996" />
    <display value="Acromegaly suspected (clinically or high IGF-1/growth hormone)" />
  </concept>
  <concept>
    <code value="20997" />
    <display value="Cushings disease suspected (clinically or lab testing)" />
  </concept>
  <concept>
    <code value="20998" />
    <display value="Dysfunction - decreased pituitary function (include labs)" />
  </concept>
  <concept>
    <code value="20999" />
    <display value="Prolactin &gt; 200 ug/L" />
  </concept>
  <concept>
    <code value="21000" />
    <display value="Sellar lesion &gt; 1 cm - confirmed on MRI or CT" />
  </concept>
  <concept>
    <code value="21001" />
    <display value="Visual fields compromised" />
  </concept>
  <concept>
    <code value="21002" />
    <display value="Hyperthyroidism" />
  </concept>
  <concept>
    <code value="21003" />
    <display value="Hypothyroidism" />
  </concept>
  <concept>
    <code value="21004" />
    <display value="Thyroid Nodule" />
  </concept>
  <concept>
    <code value="21005" />
    <display value="Thyroid Cancer" />
  </concept>
  <concept>
    <code value="21006" />
    <display value="TSH" />
  </concept>
  <concept>
    <code value="21007" />
    <display value="Site-Specific Suspicion of Cancer Presentations" />
  </concept>
  <concept>
    <code value="21008" />
    <display value="Non-Site Specific Suspicion of Cancer Presentations" />
  </concept>
  <concept>
    <code value="21009" />
    <display value="Breast" />
  </concept>
  <concept>
    <code value="21010" />
    <display value="Chest / Lung" />
  </concept>
  <concept>
    <code value="21011" />
    <display value="Genitourinary" />
  </concept>
  <concept>
    <code value="21012" />
    <display value="Gynecologic" />
  </concept>
  <concept>
    <code value="21013" />
    <display value="Head &amp; Neck" />
  </concept>
  <concept>
    <code value="21014" />
    <display value="Hepatobiliary Pancreatic" />
  </concept>
  <concept>
    <code value="21015" />
    <display value="Luminal Upper and Lower Gastrointestinal" />
  </concept>
  <concept>
    <code value="21016" />
    <display value="Cutaneous Skin / Soft Tissue" />
  </concept>
  <concept>
    <code value="21017" />
    <display value="Suspicious imaging for malignancy" />
  </concept>
  <concept>
    <code value="21018" />
    <display value="Constitutional" />
  </concept>
  <concept>
    <code value="21019" />
    <display value="Hematologic" />
  </concept>
  <concept>
    <code value="21020" />
    <display value="Unintentional, unexplained =10% weight loss (6�12 months, or shorter if severe)" />
  </concept>
  <concept>
    <code value="21021" />
    <display value="Persistent, unexplained fatigue, functionally impairing and not relieved by rest" />
  </concept>
  <concept>
    <code value="21022" />
    <display value="Bone pain - long bone or spine" />
  </concept>
  <concept>
    <code value="21023" />
    <display value="Persistent or unexplained abdominal pain" />
  </concept>
  <concept>
    <code value="21024" />
    <display value="Persistent or unexplained pelvic pain" />
  </concept>
  <concept>
    <code value="21025" />
    <display value="Subacute or progressive neurologic symptoms" />
  </concept>
  <concept>
    <code value="21026" />
    <display value="Leukemia-pattern blood abnormalities" />
  </concept>
  <concept>
    <code value="21027" />
    <display value="Lymphoma-pattern presentation" />
  </concept>
  <concept>
    <code value="21028" />
    <display value="MDS/MPN/Myeloma-pattern presentation" />
  </concept>
  <concept>
    <code value="21029" />
    <display value="Abnormal Imaging" />
  </concept>
  <concept>
    <code value="21036" />
    <display value="Medical Issue Affecting Pregnancy" />
  </concept>
  <concept>
    <code value="21037" />
    <display value="Perioperative Assessment" />
  </concept>
  <concept>
    <code value="21039" />
    <display value="Thyroid" />
  </concept>
  <concept>
    <code value="21040" />
    <display value="Unexplained Weight Loss" />
  </concept>
  <concept>
    <code value="21041" />
    <display value="Anemia" />
  </concept>
  <concept>
    <code value="21042" />
    <display value="Arrhythmia" />
  </concept>
  <concept>
    <code value="21046" />
    <display value="Preconception" />
  </concept>
  <concept>
    <code value="21047" />
    <display value="Thrombocytopenia" />
  </concept>
  <concept>
    <code value="21049" />
    <display value="Venous Thromboembolism" />
  </concept>
  <concept>
    <code value="21050" />
    <display value="Behavioural" />
  </concept>
  <concept>
    <code value="21051" />
    <display value="Cardiac" />
  </concept>
  <concept>
    <code value="21052" />
    <display value="Developmental / Growth" />
  </concept>
  <concept>
    <code value="21053" />
    <display value="Dermatologic" />
  </concept>
  <concept>
    <code value="21054" />
    <display value="Endocrine" />
  </concept>
  <concept>
    <code value="21055" />
    <display value="Gastrointestinal" />
  </concept>
  <concept>
    <code value="21056" />
    <display value="Genetic" />
  </concept>
  <concept>
    <code value="21058" />
    <display value="Musculoskeletal / Rheumatologic" />
  </concept>
  <concept>
    <code value="21059" />
    <display value="Neonatal" />
  </concept>
  <concept>
    <code value="21060" />
    <display value="Mental Health" />
  </concept>
  <concept>
    <code value="21061" />
    <display value="Neurologic" />
  </concept>
  <concept>
    <code value="21062" />
    <display value="Renal" />
  </concept>
  <concept>
    <code value="21063" />
    <display value="Respiratory" />
  </concept>
  <concept>
    <code value="21064" />
    <display value="Attention Deficit Hyperactivity Disorder (ADHD)" />
  </concept>
  <concept>
    <code value="21065" />
    <display value="Autism Spectrum Disorder (ASD)" />
  </concept>
  <concept>
    <code value="21067" />
    <display value="Palpitations" />
  </concept>
  <concept>
    <code value="21069" />
    <display value="Fine Motor Delay" />
  </concept>
  <concept>
    <code value="21070" />
    <display value="Gross Motor Delay" />
  </concept>
  <concept>
    <code value="21071" />
    <display value="Growth Concerns" />
  </concept>
  <concept>
    <code value="21072" />
    <display value="Learning Disability / Learning Problem" />
  </concept>
  <concept>
    <code value="21073" />
    <display value="Speech or Language Disorder" />
  </concept>
  <concept>
    <code value="21074" />
    <display value="Failure to Thrive" />
  </concept>
  <concept>
    <code value="21075" />
    <display value="Atopic Dermatitis" />
  </concept>
  <concept>
    <code value="21076" />
    <display value="Birth Mark" />
  </concept>
  <concept>
    <code value="21077" />
    <display value="Hemangioma" />
  </concept>
  <concept>
    <code value="21078" />
    <display value="Rash" />
  </concept>
  <concept>
    <code value="21080" />
    <display value="Gender Dysphoria" />
  </concept>
  <concept>
    <code value="21081" />
    <display value="Menstrual Irregularities" />
  </concept>
  <concept>
    <code value="21082" />
    <display value="Obesity" />
  </concept>
  <concept>
    <code value="21083" />
    <display value="Premature or Delayed Puberty" />
  </concept>
  <concept>
    <code value="21084" />
    <display value="Short Stature" />
  </concept>
  <concept>
    <code value="21085" />
    <display value="Thyroid Dysfunction" />
  </concept>
  <concept>
    <code value="21086" />
    <display value="Abdominal Pain" />
  </concept>
  <concept>
    <code value="21089" />
    <display value="Encopresis" />
  </concept>
  <concept>
    <code value="21090" />
    <display value="GERD" />
  </concept>
  <concept>
    <code value="21091" />
    <display value="Dysmorphic / Syndromic" />
  </concept>
  <concept>
    <code value="21092" />
    <display value="Family History of Known Genetic Disorder" />
  </concept>
  <concept>
    <code value="21093" />
    <display value="Trisomy 21" />
  </concept>
  <concept>
    <code value="21096" />
    <display value="Neutropenia" />
  </concept>
  <concept>
    <code value="21098" />
    <display value="Gait Concerns" />
  </concept>
  <concept>
    <code value="21099" />
    <display value="Joint / Bone Pain" />
  </concept>
  <concept>
    <code value="21100" />
    <display value="Joint Swelling" />
  </concept>
  <concept>
    <code value="21101" />
    <display value="Scoliosis" />
  </concept>
  <concept>
    <code value="21102" />
    <display value="Feeding Difficulties" />
  </concept>
  <concept>
    <code value="21103" />
    <display value="Hyperbilirubinemia" />
  </concept>
  <concept>
    <code value="21104" />
    <display value="Low Birth Weight" />
  </concept>
  <concept>
    <code value="21105" />
    <display value="Neonatal Seizures" />
  </concept>
  <concept>
    <code value="21106" />
    <display value="Prematurity" />
  </concept>
  <concept>
    <code value="21107" />
    <display value="Anxiety" />
  </concept>
  <concept>
    <code value="21108" />
    <display value="Depression" />
  </concept>
  <concept>
    <code value="21109" />
    <display value="Epilepsy" />
  </concept>
  <concept>
    <code value="21110" />
    <display value="Febrile Seizure(s)" />
  </concept>
  <concept>
    <code value="21111" />
    <display value="Headaches" />
  </concept>
  <concept>
    <code value="21112" />
    <display value="Tics" />
  </concept>
  <concept>
    <code value="21113" />
    <display value="Enuresis" />
  </concept>
  <concept>
    <code value="21115" />
    <display value="UTI(s)" />
  </concept>
  <concept>
    <code value="21117" />
    <display value="Persistent Cough" />
  </concept>
  <concept>
    <code value="21118" />
    <display value="Upper and Lower Respiratory Issues" />
  </concept>
  <concept>
    <code value="21119" />
    <display value="Abdominal Lesion / Mass" />
  </concept>
  <concept>
    <code value="21120" />
    <display value="Abdominal Pain NYD - Chronic" />
  </concept>
  <concept>
    <code value="21121" />
    <display value="Anorectal / Perianal Conditions" />
  </concept>
  <concept>
    <code value="21122" />
    <display value="Breast Conditions" />
  </concept>
  <concept>
    <code value="21123" />
    <display value="Colonoscopy - Screening / Surveillance" />
  </concept>
  <concept>
    <code value="21124" />
    <display value="Colorectal Conditions" />
  </concept>
  <concept>
    <code value="21126" />
    <display value="Hepatobiliary &amp; Pancreatic Conditions" />
  </concept>
  <concept>
    <code value="21127" />
    <display value="Hernias" />
  </concept>
  <concept>
    <code value="21128" />
    <display value="Rectal Bleeding NYD" />
  </concept>
  <concept>
    <code value="21129" />
    <display value="Skin &amp; Soft-Tissue Lesions" />
  </concept>
  <concept>
    <code value="21130" />
    <display value="Upper GI Tract Disorder" />
  </concept>
  <concept>
    <code value="21131" />
    <display value="Anal Region Disorders (e.g. fissures, fistulas, hemorrhoids)" />
  </concept>
  <concept>
    <code value="21132" />
    <display value="Fecal Incontinence" />
  </concept>
  <concept>
    <code value="21133" />
    <display value="Pilonidal Disease" />
  </concept>
  <concept>
    <code value="21134" />
    <display value="Rectal Prolapse" />
  </concept>
  <concept>
    <code value="21135" />
    <display value="Breast Lump" />
  </concept>
  <concept>
    <code value="21138" />
    <display value="Screening" />
  </concept>
  <concept>
    <code value="21139" />
    <display value="Surveillance" />
  </concept>
  <concept>
    <code value="21140" />
    <display value="Colorectal Lesion / Mass (e.g. polyp, cancer)" />
  </concept>
  <concept>
    <code value="21141" />
    <display value="Diverticulitis" />
  </concept>
  <concept>
    <code value="21142" />
    <display value="Inflammatory Bowel Disease" />
  </concept>
  <concept>
    <code value="21144" />
    <display value="Parathyroid Disease" />
  </concept>
  <concept>
    <code value="21145" />
    <display value="Thyroid Mass / Enlargement" />
  </concept>
  <concept>
    <code value="21146" />
    <display value="Gallbladder / Gallstone Disease" />
  </concept>
  <concept>
    <code value="21147" />
    <display value="Gallbladder Polyp / Mass" />
  </concept>
  <concept>
    <code value="21148" />
    <display value="Liver Lesion / Mass" />
  </concept>
  <concept>
    <code value="21149" />
    <display value="Pancreatic Lesion / Mass" />
  </concept>
  <concept>
    <code value="21150" />
    <display value="Inguinal Hernia" />
  </concept>
  <concept>
    <code value="21151" />
    <display value="Umbilical / Epigastric Hernia" />
  </concept>
  <concept>
    <code value="21152" />
    <display value="Ventral / Incisional Hernia" />
  </concept>
  <concept>
    <code value="21153" />
    <display value="Benign Lesion (e.g. lipoma, cyst)" />
  </concept>
  <concept>
    <code value="21154" />
    <display value="Lymph Node" />
  </concept>
  <concept>
    <code value="21156" />
    <display value="First-degree relative(s) with colorectal cancer" />
  </concept>
  <concept>
    <code value="21157" />
    <display value="Hereditary cancer syndrome" />
  </concept>
  <concept>
    <code value="21158" />
    <display value="First-degree relative(s) with documented advanced polyps before age 60" />
  </concept>
  <concept>
    <code value="21159" />
    <display value="Frailty or Health / Social Complexity" />
  </concept>
  <concept>
    <code value="21160" />
    <display value="Goals of Care and Future Planning" />
  </concept>
  <concept>
    <code value="21161" />
    <display value="Medication Review / Advice" />
  </concept>
  <concept>
    <code value="21162" />
    <display value="Mind or Mood" />
  </concept>
  <concept>
    <code value="21163" />
    <display value="Mobility" />
  </concept>
  <concept>
    <code value="21164" />
    <display value="Caregiver Burden" />
  </concept>
  <concept>
    <code value="21165" />
    <display value="Complex Psychosocial / Economic" />
  </concept>
  <concept>
    <code value="21166" />
    <display value="Frailty" />
  </concept>
  <concept>
    <code value="21167" />
    <display value="Generalized Functional Decline" />
  </concept>
  <concept>
    <code value="21168" />
    <display value="Multi-morbidity" />
  </concept>
  <concept>
    <code value="21172" />
    <display value="Cognitive Impairment" />
  </concept>
  <concept>
    <code value="21173" />
    <display value="Mood Disorder" />
  </concept>
  <concept>
    <code value="21174" />
    <display value="Responsive Behaviours (e.g. aggression, wandering etc...)" />
  </concept>
  <concept>
    <code value="21175" />
    <display value="Psychotic Symptoms (e.g. hallucinations, delusions, etc...)" />
  </concept>
  <concept>
    <code value="21176" />
    <display value="Impaired Gait / Balance" />
  </concept>
  <concept>
    <code value="21177" />
    <display value="Falls" />
  </concept>
  <concept>
    <code value="21198" />
    <display value="General Neurosurgery" />
  </concept>
  <concept>
    <code value="21199" />
    <display value="Cranial / Brain &amp; Skull Lesions" />
  </concept>
  <concept>
    <code value="21201" />
    <display value="Hydrocephalus / Cerebrospinal Fluid (CSF)" />
  </concept>
  <concept>
    <code value="21202" />
    <display value="Neurovascular" />
  </concept>
  <concept>
    <code value="21205" />
    <display value="Cranial Arachnoid Cyst" />
  </concept>
  <concept>
    <code value="21206" />
    <display value="Chiari Malformation" />
  </concept>
  <concept>
    <code value="21207" />
    <display value="Microvascular Decompression - Trigeminal Neuralgia, Hemifacial Spasm" />
  </concept>
  <concept>
    <code value="21208" />
    <display value="Neurosurgery Spine (intradural pathology) - Syrinx, Arachnoid Cyst, Tumour, Tethered Cord, etc." />
  </concept>
  <concept>
    <code value="21209" />
    <display value="Subdural Hematoma - Chronic" />
  </concept>
  <concept>
    <code value="21210" />
    <display value="Brain Tumour - Primary" />
  </concept>
  <concept>
    <code value="21211" />
    <display value="Brain Tumour - Metastatic" />
  </concept>
  <concept>
    <code value="21212" />
    <display value="Meningioma" />
  </concept>
  <concept>
    <code value="21213" />
    <display value="Pituitary / Sellar Lesion" />
  </concept>
  <concept>
    <code value="21214" />
    <display value="Skull Base / Cranial Nerve Tumour" />
  </concept>
  <concept>
    <code value="21215" />
    <display value="Epilepsy Surgery Assessment" />
  </concept>
  <concept>
    <code value="21216" />
    <display value="Neuromodulation for Pain" />
  </concept>
  <concept>
    <code value="21217" />
    <display value="Parkinson's - Deep Brain Stimulation Surgical Assessment" />
  </concept>
  <concept>
    <code value="21218" />
    <display value="Other Movement Disorder - Deep Brain Stimulation Surgical Assessment" />
  </concept>
  <concept>
    <code value="21219" />
    <display value="CSF Shunt Assessment (Insertion / Revision / Removal)" />
  </concept>
  <concept>
    <code value="21220" />
    <display value="Hydrocephalus - Normal Pressure (NPH)" />
  </concept>
  <concept>
    <code value="21221" />
    <display value="Hydrocephalus - Other (non-NPH)" />
  </concept>
  <concept>
    <code value="21222" />
    <display value="Arteriovenous Malformation (AVM) / Dural AV Fistula" />
  </concept>
  <concept>
    <code value="21223" />
    <display value="Brain Aneurysm - Unruptured" />
  </concept>
  <concept>
    <code value="21224" />
    <display value="Carotid Stenosis" />
  </concept>
  <concept>
    <code value="21225" />
    <display value="Cavernous Malformation" />
  </concept>
  <concept>
    <code value="21226" />
    <display value="Brachial Plexus Injury/Lesion" />
  </concept>
  <concept>
    <code value="21229" />
    <display value="Ulnar Nerve Entrapment" />
  </concept>
  <concept>
    <code value="21230" />
    <display value="Other Focal Nerve Entrapment (radial, peroneal, etc.)" />
  </concept>
  <concept>
    <code value="21231" />
    <display value="Cervical" />
  </concept>
  <concept>
    <code value="21232" />
    <display value="Thoracic" />
  </concept>
  <concept>
    <code value="21233" />
    <display value="Lumbar" />
  </concept>
  <concept>
    <code value="21234" />
    <display value="Congenital Hemolytic Anemia" />
  </concept>
  <concept>
    <code value="21236" />
    <display value="Hereditary Spherocytosis" />
  </concept>
  <concept>
    <code value="21238" />
    <display value="Thalassemia" />
  </concept>
  <concept>
    <code value="21239" />
    <display value="Uncomplicated Hemoglobinopathy Trait (Sickle Trait, Thalassemia Trait)" />
  </concept>
  <concept>
    <code value="21240" />
    <display value="Aneurysm / Dissection - Asymptomatic" />
  </concept>
  <concept>
    <code value="21241" />
    <display value="Carotid Stenosis - Asymptomatic" />
  </concept>
  <concept>
    <code value="21242" />
    <display value="Diabetic Foot Ulcers" />
  </concept>
  <concept>
    <code value="21243" />
    <display value="Peripheral Arterial Disease" />
  </concept>
  <concept>
    <code value="21244" />
    <display value="Venous Disease" />
  </concept>
  <concept>
    <code value="21245" />
    <display value="Abdominal Aortic Aneurysm (AAA)" />
  </concept>
  <concept>
    <code value="21246" />
    <display value="Descending Thoracic Aortic Aneurysm, Pathology or Dissection" />
  </concept>
  <concept>
    <code value="21247" />
    <display value="Other Aneurysm (e.g. Popliteal, Visceral, Renal)" />
  </concept>
  <concept>
    <code value="21248" />
    <display value="With high risk features (e.g. ulcerated / irregular plaque, plaque hemorrhage, contralateral ICA occlusion, progressive stenosis, young patients)" />
  </concept>
  <concept>
    <code value="21249" />
    <display value="Symptoms within 2 weeks to 6 months and more than 50% ICA stenosis" />
  </concept>
  <concept>
    <code value="21250" />
    <display value="Without high risk features, more than 50% ICA stenosis and no symptoms within 6 months" />
  </concept>
  <concept>
    <code value="21251" />
    <display value="Ulcer" />
  </concept>
  <concept>
    <code value="21252" />
    <display value="Active infection" />
  </concept>
  <concept>
    <code value="21254" />
    <display value="Asymptomatic" />
  </concept>
  <concept>
    <code value="21255" />
    <display value="Claudication" />
  </concept>
  <concept>
    <code value="21256" />
    <display value="Chronic Limb-Threatening Ischemia (e.g. rest pain, tissue loss)" />
  </concept>
  <concept>
    <code value="21257" />
    <display value="Upper Extremity Disease" />
  </concept>
  <concept>
    <code value="21258" />
    <display value="Varicose Veins with complication" />
  </concept>
  <concept>
    <code value="21259" />
    <display value="Varicose Veins without complication" />
  </concept>
  <concept>
    <code value="21260" />
    <display value="Upper Extremity Venous Disease" />
  </concept>
  <concept>
    <code value="21261" />
    <display value="Currently Pregnant" />
  </concept>
  <concept>
    <code value="21262" />
    <display value="Currently Pregnant or &lt;12 Months Postpartum" />
  </concept>
  <concept>
    <code value="21264" />
    <display value="Second Opinion" />
  </concept>
  <concept>
    <code value="21265" />
    <display value="Recent Hospitalization or ER Visit for this issue" />
  </concept>
  <concept>
    <code value="21266" />
    <display value="&lt; 1 Year Old" />
  </concept>
  <concept>
    <code value="21267" />
    <display value="Referral for child or youth (&lt;18 years old)" />
  </concept>
  <concept>
    <code value="21268" />
    <display value="Preoperative Management" />
  </concept>
  <concept>
    <code value="21269" />
    <display value="Cognitively impaired" />
  </concept>
  <concept>
    <code value="21270" />
    <display value="Falls risk" />
  </concept>
  <concept>
    <code value="21271" />
    <display value="Hearing impaired" />
  </concept>
  <concept>
    <code value="21272" />
    <display value="Patient requires lift" />
  </concept>
  <concept>
    <code value="21273" />
    <display value="Vision impaired" />
  </concept>
  <concept>
    <code value="21274" />
    <display value="Wheelchair" />
  </concept>
  <concept>
    <code value="21275" />
    <display value="Allied Health Professional" />
  </concept>
  <concept>
    <code value="21276" />
    <display value="Family Physician" />
    <designation>
      <language value="fr" />
      <value value="Médecin de famille" />
    </designation>
  </concept>
  <concept>
    <code value="21277" />
    <display value="Physician Assistant" />
  </concept>
  <concept>
    <code value="21278" />
    <display value="Medical Student" />
  </concept>
  <concept>
    <code value="21279" />
    <display value="Nurse" />
  </concept>
  <concept>
    <code value="21280" />
    <display value="Nurse Practitioner" />
  </concept>
  <concept>
    <code value="21281" />
    <display value="Resident" />
  </concept>
  <concept>
    <code value="21282" />
    <display value="Specialist" />
  </concept>
  <concept>
    <code value="21283" />
    <display value="No known kidney issues" />
    <designation>
      <language value="fr" />
      <value value="Aucun problème rénal connu" />
    </designation>
  </concept>
  <concept>
    <code value="21284" />
    <display value="Yes, patient has impaired renal function or a history of renal transplant" />
  </concept>
  <concept>
    <code value="21285" />
    <display value="eGFR result" />
  </concept>
  <concept>
    <code value="21286" />
    <display value="Has diabetes" />
  </concept>
  <concept>
    <code value="21287" />
    <display value="On dialysis" />
  </concept>
  <concept>
    <code value="21288" />
    <display value="Known hypersensitivity to contrast agents" />
  </concept>
  <concept>
    <code value="21289" />
    <display value="History of reaction before the year 2000" />
  </concept>
  <concept>
    <code value="21291" />
    <display value="Estimated Date of Delivery" />
  </concept>
  <concept>
    <code value="21292" />
    <display value="Last Menstrual Period" />
  </concept>
  <concept>
    <code value="21293" />
    <display value="Currently breastfeeding" />
    <designation>
      <language value="fr" />
      <value value="Allaite actuellement" />
    </designation>
  </concept>
  <concept>
    <code value="21294" />
    <display value="Claustrophobia" />
  </concept>
  <concept>
    <code value="21295" />
    <display value="Require general anesthesia" />
  </concept>
  <concept>
    <code value="21296" />
    <display value="Has metal fragments in eye(s)/body" />
  </concept>
  <concept>
    <code value="21297" />
    <display value="Has active electronic implants (e.g. Cardiac Implantable Electronic Device, Neurostimulator, Cochlear Implant, Medication Pump, etc.) or retained parts (e.g. leads, etc.):" />
  </concept>
  <concept>
    <code value="21298" />
    <display value="Has other metal containing devices (e.g. Aneurysm Clip, IUD, Tissue Expander, Shunt, Stent, Coil, Traction Device, Glucose Monitor, etc.), metal foreign bodies (Shrapnel, Bullets, Subdermal Piercings, Etc), or orthopedic device:" />
  </concept>
  <concept>
    <code value="21299" />
    <display value="CIED" />
  </concept>
  <concept>
    <code value="21300" />
    <display value="Neurostimulator" />
  </concept>
  <concept>
    <code value="21301" />
    <display value="Cochlear Implant" />
  </concept>
  <concept>
    <code value="21302" />
    <display value="Medication Pump" />
  </concept>
  <concept>
    <code value="21303" />
    <display value="Aneurysm Clip" />
  </concept>
  <concept>
    <code value="21304" />
    <display value="Coil" />
  </concept>
  <concept>
    <code value="21305" />
    <display value="Glucose Monitor" />
  </concept>
  <concept>
    <code value="21306" />
    <display value="Heart Valve" />
  </concept>
  <concept>
    <code value="21307" />
    <display value="Copper or Stainless Steel IUD" />
  </concept>
  <concept>
    <code value="21308" />
    <display value="Orthopedic Devices" />
  </concept>
  <concept>
    <code value="21309" />
    <display value="Pessary" />
  </concept>
  <concept>
    <code value="21310" />
    <display value="Prosthesis" />
  </concept>
  <concept>
    <code value="21311" />
    <display value="Shunt" />
  </concept>
  <concept>
    <code value="21312" />
    <display value="Stent" />
  </concept>
  <concept>
    <code value="21313" />
    <display value="Subdermal Piercings" />
  </concept>
  <concept>
    <code value="21314" />
    <display value="Tissue Expander" />
  </concept>
  <concept>
    <code value="21315" />
    <display value="Traction Device" />
  </concept>
  <concept>
    <code value="21316" />
    <display value="Patient has impaired renal function or a history of renal transplant" />
  </concept>
  <concept>
    <code value="21317" />
    <display value="She/Her" />
  </concept>
  <concept>
    <code value="21318" />
    <display value="He/Him" />
  </concept>
  <concept>
    <code value="21319" />
    <display value="They/Them" />
  </concept>
  <concept>
    <code value="21320" />
    <display value="Immunocompromised" />
  </concept>
  <concept>
    <code value="21321" />
    <display value="Left" />
  </concept>
  <concept>
    <code value="21322" />
    <display value="Right" />
  </concept>
  <concept>
    <code value="21323" />
    <display value="Bilateral" />
    <designation>
      <language value="fr" />
      <value value="Bilatéral" />
    </designation>
  </concept>
  <concept>
    <code value="21324" />
    <display value="Patient cannot provide reliable medical history or provide consent to contrast injections (where applicable)" />
  </concept>
  <concept>
    <code value="21325" />
    <display value="Abnormal Lab Finding" />
  </concept>
  <concept>
    <code value="21326" />
    <display value="Vomiting" />
  </concept>
  <concept>
    <code value="21327" />
    <display value="Weight Loss" />
  </concept>
  <concept>
    <code value="21328" />
    <display value="Eating Concerns" />
  </concept>
  <concept>
    <code value="21329" />
    <display value="Custody Considerations" />
  </concept>
  <concept>
    <code value="21330" />
    <display value="Child Welfare Agency Involvement (e.g., Children's Aid Society)" />
  </concept>
  <concept>
    <code value="21331" />
    <display value="Suspected Malignancy" />
  </concept>
  <concept>
    <code value="21332" />
    <display value="Confirmed Malignancy" />
  </concept>
  <concept>
    <code value="21333" />
    <display value="Endocrine Conditions" />
  </concept>
  <concept>
    <code value="21344" />
    <display value="Breast Inflammation / Abscess" />
  </concept>
  <concept>
    <code value="21345" />
    <display value="Imaging Abnormality" />
  </concept>
  <concept>
    <code value="21346" />
    <display value="Wound Management" />
  </concept>
  <concept>
    <code value="21347" />
    <display value="G6PD Deficiency" />
  </concept>
  <concept>
    <code value="21348" />
    <display value="PK Deficiency" />
  </concept>
  <concept>
    <code value="21349" />
    <display value="HbSS" />
  </concept>
  <concept>
    <code value="21350" />
    <display value="HbSC" />
  </concept>
  <concept>
    <code value="21351" />
    <display value="HbS/�-thalassemia" />
  </concept>
  <concept>
    <code value="21352" />
    <display value="Transfusion-Dependent Thalassemia" />
  </concept>
  <concept>
    <code value="21353" />
    <display value="Non-Transfusion-Dependent Thalassemia" />
  </concept>
  <concept>
    <code value="21354" />
    <display value="Movement Disorder" />
  </concept>
  <concept>
    <code value="21355" />
    <display value="Unintentional Weight Change / Nutritional Concerns" />
  </concept>
  <concept>
    <code value="21356" />
    <display value="Sleep Concerns" />
  </concept>
  <concept>
    <code value="21357" />
    <display value="Arrived in Canada in past 3-6 months" />
  </concept>
  <concept>
    <code value="21358" />
    <display value="Recent or Ongoing Complications" />
  </concept>
  <concept>
    <code value="21359" />
    <display value="Referred from Sickle Cell Comprehensive Care Clinic" />
  </concept>
  <concept>
    <code value="21360" />
    <display value="Requires ongoing Red Blood Cell transfusion support" />
  </concept>
  <concept>
    <code value="21361" />
    <display value="Transfer of care" />
  </concept>
  <concept>
    <code value="21362" />
    <display value="Non-Invasive Vascular Testing" />
  </concept>
  <concept>
    <code value="21363" />
    <display value="Vascular Consultation" />
  </concept>
  <concept>
    <code value="21364" />
    <display value="Nerve Root Impingement / Radiculopathy Present" />
  </concept>
  <concept>
    <code value="21365" />
    <display value="Functional Neurosurgery - Surgical Assessment (Epilepsy, Movement, Pain)" />
  </concept>
  <concept>
    <code value="21366" />
    <display value="Adrenals" />
  </concept>
  <concept>
    <code value="21367" />
    <display value="Bone" />
  </concept>
  <concept>
    <code value="21368" />
    <display value="Kidneys" />
  </concept>
  <concept>
    <code value="21369" />
    <display value="Liver" />
  </concept>
  <concept>
    <code value="21370" />
    <display value="Lung" />
  </concept>
  <concept>
    <code value="21371" />
    <display value="Lymph nodes" />
  </concept>
  <concept>
    <code value="21372" />
    <display value="Mediastinal mass" />
  </concept>
  <concept>
    <code value="21373" />
    <display value="Pancreas" />
  </concept>
  <concept>
    <code value="21374" />
    <display value="Pelvis" />
  </concept>
  <concept>
    <code value="21375" />
    <display value="Thoracic Outlet Syndrome" />
  </concept>
  <concept>
    <code value="21376" />
    <display value="Arterial" />
  </concept>
  <concept>
    <code value="21377" />
    <display value="Venous" />
  </concept>
  <concept>
    <code value="21378" />
    <display value="Arm" />
  </concept>
  <concept>
    <code value="21379" />
    <display value="Leg" />
  </concept>
  <concept>
    <code value="21380" />
    <display value="Ankle brachial index (screening)" />
  </concept>
  <concept>
    <code value="21381" />
    <display value="Fasting" />
  </concept>
  <concept>
    <code value="21382" />
    <display value="Post-prandial" />
  </concept>
  <concept>
    <code value="21383" />
    <display value="Existing PICC line" />
  </concept>
  <concept>
    <code value="21384" />
    <display value="Existing Port-a-Cath" />
  </concept>
  <concept>
    <code value="21385" />
    <display value="What is the patient's current resting heart rate (bpm)?" />
  </concept>
  <concept>
    <code value="21386" />
    <display value="Known contraindications to Nitroglycerin:" />
  </concept>
  <concept>
    <code value="21387" />
    <display value="Is the patient currently on beta-blockers?" />
  </concept>
  <concept>
    <code value="21388" />
    <display value="Severe/critical aortic stenosis" />
  </concept>
  <concept>
    <code value="21389" />
    <display value="Severe symptomatic aortic insufficiency" />
  </concept>
  <concept>
    <code value="21390" />
    <display value="Decompensated congestive heart failure" />
  </concept>
  <concept>
    <code value="21391" />
    <display value="Allergy to Beta-blockers" />
  </concept>
  <concept>
    <code value="21392" />
    <display value="Prior hospitalization for lung disease" />
  </concept>
  <concept>
    <code value="21393" />
    <display value="Active bronchospasm" />
  </concept>
  <concept>
    <code value="21394" />
    <display value="2nd or 3rd degree heart block, or 1st degree with PR&gt;0.42s" />
  </concept>
  <concept>
    <code value="21395" />
    <display value="Will the patient be prescribed a beta-blocker?" />
  </concept>
  <concept>
    <code value="21396" />
    <display value="Spinal Cord Compression Present" />
  </concept>
  <concept>
    <code value="21397" />
    <display value="Date of First Suspicion of Cancer" />
  </concept>
  <concept>
    <code value="21398" />
    <display value="Abdomen Pelvis Angiography" />
  </concept>
  <concept>
    <code value="21399" />
    <display value="None of the above" />
  </concept>
  <concept>
    <code value="21400" />
    <display value="Unsure/Unknown" />
  </concept>
  <concept>
    <code value="21401" />
    <display value="Intersex" />
  </concept>
  <concept>
    <code value="21402" />
    <display value="Other" />
  </concept>
  <concept>
    <code value="21403" />
    <display value="Translator Required" />
  </concept>
  <concept>
    <code value="21404" />
    <display value="Preferred Name" />
  </concept>
  <concept>
    <code value="21405" />
    <display value="Voicemails acceptable" />
  </concept>
  <concept>
    <code value="21406" />
    <display value="Alternate contact" />
  </concept>
  <concept>
    <code value="21407" />
    <display value="Yes" />
  </concept>
  <concept>
    <code value="21408" />
    <display value="No" />
  </concept>
  <concept>
    <code value="21409" />
    <display value="Unsafe contact persons (do not speak with)" />
  </concept>
  <concept>
    <code value="21410" />
    <display value="Only speak with patient directly" />
  </concept>
  <concept>
    <code value="21411" />
    <display value="Accessibility concerns or disability" />
  </concept>
  <concept>
    <code value="21412" />
    <display value="Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)" />
  </concept>
  <concept>
    <code value="21413" />
    <display value="Send copies of reports to additional providers" />
  </concept>
  <concept>
    <code value="21414" />
    <display value="This is the Primary Care Provider" />
  </concept>
  <concept>
    <code value="21415" />
    <display value="CPP attached separately (if not entered below)" />
  </concept>
  <concept>
    <code value="21416" />
    <display value="Preferred consultant or location" />
  </concept>
  <concept>
    <code value="21417" />
    <display value="Patient willing to travel for shorter wait time" />
  </concept>
  <concept>
    <code value="21418" />
    <display value="Personal Health Information that is medically relevant has not been disclosed at the request of the patient." />
  </concept>
  <concept>
    <code value="21419" />
    <display value="OHIP" />
  </concept>
  <concept>
    <code value="21420" />
    <display value="WSIB Case" />
  </concept>
  <concept>
    <code value="21421" />
    <display value="DND" />
  </concept>
  <concept>
    <code value="21422" />
    <display value="IFH" />
  </concept>
  <concept>
    <code value="21423" />
    <display value="RAMQ" />
  </concept>
</CodeSystem>