Patient Attachment Initiative

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Please affix patient label (if available)
PATIENT ATTACHMENT INITIATIVE
MOTHER-INFANT DYAD
Patient Referral for Family Doctor Attachment
CRITERIA FOR REFERRAL
--- PLEASE CONFIRM PATIENT ELIGIBLITY BY CHECKING ALL BOXES BELOW ---
Patients who do not meet all of these requirements are not eligible to be matched through this program.
¨
The patient:
is a city of Vancouver resident
¨
speaks English
(or is able to bring someone who speaks English to appointments)
¨
does not have a family doctor providing continuing care
(eg has not seen family doctor >18 months)
¨
must have active (or pending) MSP coverage
¨
has relatively stable mental health, medical condition and addiction at time of referral.
¨
is able to comfortably call to schedule and attend appointments in a medical office.
PATIENT CONSENT
I, __________________________________, consent to a summary of the clinical information FOR MYSELF AND MY
CHILD being sent to the Vancouver Division of Family Practice Attachment Facilitator (a health care professional) for
the purposes of (a): potentially referring my personal health information to a family doctor within the community and (b):
recording non-identifying personal health information for the purposes of evaluating the Patient Attachment Initiative. I
also understand that the Vancouver Division of Family Practice cannot guarantee a match with a family doctor, and that
I may need to continue to search for a family doctor on my own.
--- Please EITHER have patient/decision maker sign consent OR obtain verbal consent ---
______________________________________
Patient/substitute decision maker:
Date:_____________
Signature
(DD/MM/YYYY)
If substitute decision maker, please state relationship: __________________________________________________
Verbal consent obtained by:________________________ __________________________ Date:_____________
Print name
Signature
(DD/MM/YYYY)
Witness (if substitute/verbal consent): __________________________________________ Date:_____________
Signature
(DD/MM/YYYY)
REFERRAL FOR FAMILY DOCTOR ATTACHMENT
Referral requested on:___________________________ Expected date of delivery: ___________________________
(DD/MM/YYYY)
(DD/MM/YYYY)
◻
◻
◻
◻
◻
Referral source:
Obstetrician
Maternity GP
Midwife
Public Health Nurse
Other: ____________________
Name of person referring: _______________________________ Practice name:_____________________________
Practice address: _____________________________________________________________ City: Vancouver, BC
Phone number:_______________ Fax number:_______________ Email:__________________________________
Primary Medical Reason for Family Doctor Referral: _________________________________________________
PLEASE FAX THE FOLLOWING PATIENT INFORMATION (WHERE AVAILABLE) WITH THIS REFERRAL FORM
¨
¨
¨
¨
Antenatal Record Part I
Antenatal Record Part II
Labour & Birth Summary
Newborn Record I & II
OR if Public Health Nurse
¨
¨
BC Community Liaison Record (PSBC Form 1591)
Other: _____________________________________
MOTHER’S INFORMATION
Patient’s full name:__________________________________________________________ DOB: _______________
(DD/MM/YYYY)
Address:________________________________________ City: Vancouver, BC Postal Code: __________________
Phone Number:_________________________________ Email :__________________________________________
ADDITIONAL COMMENTS::_______________________________________________________________________
604-428-6969
FAX this form and accompanying documents to the Attachment Facilitator at
604-440-7208
Questions? Please contact the Attachment Facilitator at
Rev. 11-May 2016

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