--- title: Les formulaires publiés du 1er janvier au 31 mars 2024 slug: portal-sub/les-formulaires-publies-du-1er-janvier-au-31-mars-2024 docTags: createdAt: 2026-03-04T12:03:23.589Z --- Les instructions sur la façon **d'ajouter, de configurer et de supprimer** des formulaires dans Profile peuvent être trouvées [ici](docId:0CM8L-qaJe7d6znWkJXkV). |
| Des formulaires nouveaux  |
|
| Formulaire à supprimer du DME |
| | ------ | -------------------------------------------------------------------------------------------- | ------------------- | -------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------------------------------------------ | | Objet | Nom | ID and version | Lien vers le nouveau formulaire  | Nom | ID and version | | 1 | Colposcopy Clinic Physician Referral | 953 (11/22) | [Colposcopy Clinic Physician Referral](https://help.intrahealth.com/a/solutions/articles/6000270180?lang=en) |
|
| | 2 | Dépistages du risque suicidaire - ASQ | RC-315F (2023-02) | [Dépistages du risque suicidaire - ASQ](https://help.intrahealth.com/a/solutions/articles/6000270248?lang=fr) |
|
| | 3 | Vitalite - Demande de Services - Infirmiere pivot en Oncologie | RC-281B (2022-01) | [Vitalite - Demande de Services - Infirmiere pivot en Oncologie](https://help.intrahealth.com/a/solutions/articles/6000270182?lang=fr) |
|
| | 4 | Rx COPD Action Plan | HHN-1260 (10/22) | [Rx COPD Action Plan](https://help.intrahealth.com/a/solutions/articles/6000270262?lang=en) |
|
| | 5 | Diabetes Education Centre Referral | 565 (07/23) | [Diabetes Education Centre Referral](https://help.intrahealth.com/a/solutions/articles/6000270325?lang=en) |
|
| | 6 | Demande D'Analyse De Sperme | 68.37.16 (2023-05) | [Demande D'Analyse De Sperme](https://help.intrahealth.com/a/solutions/articles/6000270207?lang=fr) |
|
| | 7 | New Brunswick Drug Plans Special Authorization Request | FORM-791E 04/20 | [New Brunswick Drug Plans Special Authorization Request](https://help.intrahealth.com/a/solutions/articles/6000271679?lang=en) | 301E - New Brunswick Drug Plans Special Authorization Request Form |
| | 8 | Imaging Exam Request - General Radiography | HHN-1237 (11/23) | [Imaging Exam Request - General Radiography](https://help.intrahealth.com/a/solutions/articles/6000270473?lang=en) |
|
| | 9 | MRI Consultation | HHN-0390 (03/21) | [MRI Consultation](https://help.intrahealth.com/a/solutions/articles/6000265269?lang=en) | 4166F- Horizon MRI consultation and Patient Safety Screening Form (formulaire anglais) |
| | 10 | Requisition and Order Form Interventional Radiology | 300000515 (06/23) | [Requisition and Order Form Interventional Radiology](https://help.intrahealth.com/a/solutions/articles/6000270235?lang=en) |
|
| | 11 | Cardiac Diagnostics Requisition | 300000516 (07/23) | [Cardiac Diagnostics Requisition](https://help.intrahealth.com/a/solutions/articles/6000270407?lang=en) |
|
| | 12 | Diabetes Education Referral and Report - Fredericton     and URV  | 300000383 (03/19) | [Diabetes Education Referral and Report - Fredericton  and URV](https://help.intrahealth.com/a/solutions/articles/6000270470?lang=en) |
|
| | 13 | Stan Cassidy Centre for Rehabilitation Rehabilitation Services Request | 02.7300-48 (08/10)D | [Stan Cassidy Centre for Rehabilitation Rehabilitation Services Request](https://help.intrahealth.com/a/solutions/articles/6000270534?lang=en) | 4173F- Demande de services de readaptation- Centre de readaptation Stan Cassidy |
| | 14 | Consultation de RI | Form 244 - 05/10  | [Consultation de RI](https://help.intrahealth.com/a/solutions/articles/6000270495?lang=fr) |
|
| | 15 | Échelle de fragilité clinique | Version 1.2 | [Échelle de fragilité clinique](https://help.intrahealth.com/a/solutions/articles/6000270513?lang=fr) |
|
| | 16 | Demande de Services - Pointe d'entree Unique (PEU) | RC-250B (2023-04) | [Demande de Services - Pointe d'entree Unique (PEU)](https://help.intrahealth.com/a/solutions/articles/6000270308?lang=fr) |
|
| | 17 | Appendix A - Confirmation of Diagnosis Form |
| [Appendix A - Confirmation of Diagnosis Form](https://help.intrahealth.com/a/solutions/articles/6000270536?lang=en) |
|
| | 18 | Zone 1B - Demande d’analyse | 18.03.18 (2011-06) | [Zone 1B - Demande d’analyse](docId\:t-zse6SCtu7qapAk00qvK) |
|
| | 19 | Sexual Health Patient Profile | 1008 (03/19) | [Sexual Health Patient Profile](https://help.intrahealth.com/a/solutions/articles/6000271055?lang=en) |
|
| | 20 | Request to Consult or Correct Personal Health Information (PHI) | RC-10E (2018-04)  | [Request to Consult or Correct Personal Health Information (PHI)](https://help.intrahealth.com/a/solutions/articles/6000270428?lang=en) |
|
| | 21 | Patient Referral Form - The Moncton Hospital Chest Clinic | 702 (01/21) | [Patient Referral Form - The Moncton Hospital Chest Clinic](docId\:T6rEDTBa6kQYxeIJjkU3g) |
|
| | 22 | Demande de Consultation | RC-259B (2021-06) | [Demande de Consultation](https://help.intrahealth.com/a/solutions/articles/6000270438?lang=fr) |
|
| | 23 | Demande de Services/Referral | RC-188B (2020-01) | [Demande de Services/Referral](https://help.intrahealth.com/a/solutions/articles/6000270480?lang=fr) |
|
| | 24 | Formulaire de Renvoi - Centre de Sante Mentale Communautaire | 2005.11 #1627-78 | [Formulaire de Renvoi - Centre de Sante Mentale Communautaire](https://help.intrahealth.com/a/solutions/articles/6000270507?lang=fr) |
|
| | 25 | Community Mental Health Centre Referral Form | 2005.11 #1627-77 | [Community Mental Health Centre Referral Form](https://help.intrahealth.com/a/solutions/articles/6000271413?lang=en) |
|
| | 26 | IWK Constitutional Molecular Genetic Testing |
| [IWK Constitutional Molecular Genetic Testing](https://help.intrahealth.com/a/solutions/articles/6000271154?lang=en) |
|
| | 27 | NB-ISAEC Patient Referral Form |
| [NB-ISAEC Patient Referral Form](https://help.intrahealth.com/a/solutions/articles/6000271433?lang=en) |
|
| | 28 | Demande de consultation pour le Cœur en santé | 17.84.49 (2019-05) | [Demande de consultation pour le Cœur en santé](https://help.intrahealth.com/a/solutions/articles/6000265432?lang=fr) | Demande de consultation pour le Cœur en santé | 17.84.49 2019-02 | | 29 | Demande de consultation en Oncologie | RC-39F (2016 03) | [Demande de consultation en Oncologie](docId\:f60H5L3ZzvLdCGZQAPLfy) | 4221F - Vitalite Demande de consultation en Oncologie - FR
 4221-Vitalite Oncology Consultation request | RC-39B 2016-02 | | 30 | Réanimation cardiorespiratoire et niveaux de soins | RC-05F (08/21) | [Réanimation cardiorespiratoire et niveaux de soins](https://help.intrahealth.com/a/solutions/articles/6000271058?lang=fr) | RC-05F Réanimation cardiorespiratoire et niveaux de soins | RC-05F 2018-09 | | 31 | Ordonnance-Dérisomaltose Ferrique IV (Monoferric) | RC-251F (01/22) | [Ordonnance-Dérisomaltose Ferrique IV (Monoferric)](https://help.intrahealth.com/a/solutions/articles/6000271059?lang=fr) | RC-251F – Ordonnances: Fer-Isomaltoside Intraveineux (Monoferric) | RC-251F 2021-04 | | 32 | Request for diagnostic tests-Central scheduling Dr Georges Dumont University Hospital centre | 68.08.03 (2016) | [Request for diagnostic tests-Central scheduling Dr Georges Dumont University Hospital centre](https://help.intrahealth.com/a/solutions/articles/6000271522?lang=fr) | 4777E Vitalite request for diagnostic tests-Central scheduling Dr Georges Dumont University Hospital centre | 68.08.03 2013-02 | | 33 | Demande de service en audiologie | 16.79.92 (04/14) | [Demande de service en audiologie](https://help.intrahealth.com/a/solutions/articles/6000271068?lang=fr) | 4250F - Vitalité Demande de Services en Readaptation
4874F - Demande de service en audiologie
 4250-Vitalite Request for Audiology Services | No ID# or date on any of them | | 34 | Demande de services professionnels  | 3120-D (08/17) | [Demande de services professionnels](https://help.intrahealth.com/a/solutions/articles/6000271185?lang=fr) | 4806F - RRS 4 - Demande de services professionnels | 3120-D 2002-10 | | 35 | Perinatal NB Antenatal record | RC-51E (01/22) | [Perinatal NB Antenatal record](https://help.intrahealth.com/a/solutions/articles/6000271067?lang=en) | 4950E Perinatal NB Antenatal record
 Antenatal record Part 2 only | RC-51E 2021-01
 RC-51E 2021-01 | | 36 | Demande de services Therapie respiratoire | R-639B (2019 02) | [Demande de services Therapie respiratoire](https://help.intrahealth.com/a/solutions/articles/6000264721?lang=fr) | 4804F - Vitalité Demande de services - Laboratoire de fonction pulmonaire - Thérapie respiratoire - Zone 6
4805F - Vitalité Demande de services - Clinique de santé respiratoire - Zone 6
 4978E Vitalite Respiratory Health clinic service request | R-639F 2017-07
R-639F 2017-07
R-639E 2017-05
| | 37 | Acadie Bathurst zone 6-Outpatient Laboratory | R-670 (2023-01) | [Acadie Bathurst zone 6-Outpatient Laboratory](https://help.intrahealth.com/a/solutions/articles/6000265233?lang=fr) | 85008F-Vitalité Acadie Bathurst zone 6-Demande d'analyses-patient externe
 85008FE-Vitalité Acadie Bathurst zone 6-Réquisition de laboratoire externe | R-670 2018-12
 R-670 2018-12 | | 38 | Demande de service/Referral -Programme Maintien a Domicile / At Home Program | RC-151B (2023-04) | [Demande de service/Referral -Programme Maintien a Domicile / At Home Program](https://help.intrahealth.com/a/solutions/articles/6000265261?lang=fr) | Demande de service Maintien a Domicile / At Home Referral bilingual form
 Demande de service maintien a domicile/ at home referral bilingual form | RC-151B 2018-11
 RC-151B 2018-11 | | 39 | Consultation epreuevs d'effort-electrodiagnostics | R-647(2018 04) | [Consultation epreuevs d'effort-electrodiagnostics](https://help.intrahealth.com/a/solutions/articles/6000265181?lang=fr) | 4869EF Vitalite consultation epreuevs d'effort | RC-647 2018-04 | | 40 | DOCUMENTATION DU QUESTIONNAIRE PRÉ-OPÉRATOIRE DU NOUVEAU-BRUNSWICK | MS (09/04) | [DOCUMENTATION DU QUESTIONNAIRE PRÉ-OPÉRATOIRE DU NOUVEAU-BRUNSWICK](https://help.intrahealth.com/a/solutions/articles/6000271057?lang=fr) | 4120F- NB Questionnaire pre-operatoire de Nouveau-Brunswick | No ID# or date | | 41 | Demande d'analyses-Service de laboratoire Zone Nord Ouest | 1948 (04/23) | [Demande d'analyses-Service de laboratoire Zone Nord Ouest](https://help.intrahealth.com/a/solutions/articles/6000271521?lang=fr) | 1072F - Vitalité Demandes d'analyse
 4928F - Lab Order - Ordonnance de lab | 1948.22222222222
 No ID# or date | | 42 | Change of Sex Designation - Adult | 12360 | [Change of Sex Designation - Adult](https://help.intrahealth.com/a/solutions/articles/6000271344?lang=en) |
|
| | 43 | Ferric Derisomaltose for Treatment of Anemia - Adult | PPO-IM-30019 | [Ferric Derisomaltose for Treatment of Anemia - Adult](https://help.intrahealth.com/a/solutions/articles/6000265675?lang=en) | Iron Isomaltoside (MONOFERRIC) for the Treatment of Anemia in Adults | PPO-IM-30019 | | 44 | RÉFÉRENCE À LA CLINIQUE DU DIABÈTE / REFERRAL TO DIABETES CLINIC | RC-316B (2024-02) | [RÉFÉRENCE À LA CLINIQUE DU DIABÈTE / REFERRAL TO DIABETES CLINIC](https://help.intrahealth.com/a/solutions/articles/6000271414?lang=fr) | 4750F-Vitalité Demande de service clinique du diabete-Zone 1B | 19.24.79 2018-08 | | 45 | Imaging Exam Request - General Radiography | HHN-1237 (02/24) | [Imaging Exam Request - General Radiography](https://help.intrahealth.com/a/solutions/articles/6000271345?lang=en) | HHN-1237 (11/23) - Imaging Exam Request - General Radiology
| HHN-1237 (11/23) |