Fax this completed form to the appropriate fax number (below) and the patient will be contacted directly
□ WEST VAN CHC
FAX 604-904-6172
Tel 604-984-5752 / □ RICHMOND (GARRATT)
FAX 604-204-2017
Tel 604-204-2007 / □ ST. PAUL’S
FAX 604-806-8680
Tel 604-806-8486; press 3 / □ UBC HOSPITAL
FAX 604-822-7903
Tel 604-822-7255 / □ VGH
FAX 604-875-4442
Tel 604-875-4120
PLEASE PRINT CLEARLY □ ALLERGIES (PLEASE LIST):
BILLABLE TO:
□ MSP □ ICBC □ WCB □ PATIENT □ OTHER / NAME / ADDRESS OF REFERRING PHYSICIAN AND MSP PRACTITIONER # (or office stamp)
PERSONAL HEALTH NUMBER: / DOB: YYYY/MM/DD
| |
SURNAME OF PATIENT, FIRST NAME AND MIDDLE INITIAL
MOST RELIABLE TELEPHONE #’S (INCLUDE AREA CODE): / □ MALE □ FEMALE
PREGNANT: □ YES □ NO
ADDRESS CITY/TOWN POSTAL CODE / COPY RESULTS TO:
□ TRANSLATION SERVICES REQUIRED: (PLEASE INDICATE LANGUAGE) ______
(24 HOUR ADVANCED NOTICE REQUIRED)
PERTINENT HISTORY
REASON FOR REFERRAL / BRIEF HISTORY:
______
PLEASE PROVIDE A LIST OF CURRENT MEDICATIONS ______
PATIENT HEIGHT ______PATIENT WEIGHT ______
GROUP PROGRAM REFERRALS (SEE LOCATIONS BELOW):
WEIGHT MANAGEMENT:
□ 7 WEEK “WINNING AT LOSING” PROGRAM (RICHMOND) – FEE TO BE PAID AT REGISTRATION□ 10 WEEK “BODY SENSE” PROGRAM (WEST VANCOUVER COMMUNITY HEALTH CENTRE)— FEE TO BE PAID AT REGISTRATION
□ 12 WEEK “BODYSENSE” PROGRAM (VGH) - FEE TO BE PAID AT REGISTRATION
MANAGEMENT OF PROBLEMATIC EATING:
□ 5 WEEK CRAVING CHANGE – (VGH) - FEE TO BE PAID AT REGISTRATION
CARDIAC:
□ Healthy Heart Eating and Exercise Program (WEST VANCOUVER COMMUNITY HEALTH CENTRE)‼ FOR ALL REFERRALS - PLEASE ATTACH ALL RECENT BLOOD /LABORATORY /PERTINENT RESULTS ‼
PLEASE NOTE:
!!ALL REFERRAL INFORMATION MUST BE COMPLETED IN FULL. INCOMPLETE REFERRALS WILL BE RETURNED!!
A FEE MAY CHARGED TO PATIENTS WHO FAIL TO PROVIDE AT LEAST 24 HOURS NOTICE OF CANCELLATION FOR A SCHEDULED APPOINTMENT OR TEST
OUR FACILITY IS A FRAGRANCE FREE ZONE
July 2015