Bc Women'S Centre Referral Form

ADVERTISEMENT

BC Women’s Centre for Pelvic Pain & Endometriosis
BC Women’s Hospital + Health Centre
F2-4500 Oak St., Vancouver, BC V6H-3N1
T 604.875.2534 / F 604.875.2569
W
REFERRAL FORM
□
□
DATE OF REFERRAL:
/
/
Re-referral?
Yes
No
(dd)
(mm)
(yy)
REFERRING PHYSICIAN:
Physician name:
Billing #:
Phone:
Fax:
□
□
Do you agree to provide ongoing care after this patient is discharged from our program?
Yes
No
If no, who agrees to provide care? _____________________________________________________________
PATIENT DETAILS:
First name:
Surname:
DOB:
PHN:
/
/
(dd)
(mm)
(yy)
Address:
City/Town:
Postal:
Home/Cell:
Work/Cell:
□
□
Does patient read, speak, and understand English?
No… Language:
Yes
□
□
If no, is an Interpreter requested?
Yes…. Request #:
(internal use)
No
REASON FOR REFERRAL:
Pelvic Pain/Endometriosis:
Gynecology:
Physician:
□
□
□
Chronic pelvic pain
Fibroids
Dr. Catherine Allaire
□
□
□
Endometriosis
Menstrual disorders
Dr. Christina Williams
□
□
Ovarian cyst(s)
Dr. Paul Yong
□
□
MIS surgery
Dr. Mohamed Bedaiwy
□
□
_________________________________
Other:
First available
DESCRIBE REASON FOR REFERRAL: (symptoms, duration, location, etc.)
_________________________________________________________________________________________
_________________________________________________________________________________________
MEDICAL RECORDS:
□
□
□
Has the patient seen another physician for this problem?
No
Yes……..…
All consult reports attached
If yes, name of physician(s): __________________________________________________________________
□
□
□
Previous imaging (u/s, CT, MRI, etc.) and bloodwork results?
N/A
Yes……
All results/reports attached
□
□
□
Has patient had previous surgery for this problem?
No
Yes……………..
All operative reports attached
Patient will not be triaged until all information regarding previous investigations is received.
Once information is received, patient will be contacted within 6 weeks to book appointment.
The wait time for an initial consult is approximately 3 to 6 months.
CPP Referral Form, Nov 2015, v. 4 | Page 1 of 1

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Women's Health History Form Women's Health History Form Medical
Women's Health Center Form Women's Health Center Form Medical
Form 13285-a - Reducing Tax Burden On America's Taxpayers (referral Form For Use By The Public) Form 13285-a - Reducing Tax Burden On America's Taxpayers (referral Form For Use By The Public) Financial
Form 13285-a - Reducing Tax Burden On America's Taxpayers (referral Form For Use By The Public) Form 13285-a - Reducing Tax Burden On America's Taxpayers (referral Form For Use By The Public) Legal
Conard High School Student Success Team (s.s.t.) Referral Form Conard High School Student Success Team (s.s.t.) Referral Form Education
Authorization For Release Of Women's Health Information Form Authorization For Release Of Women's Health Information Form Business
Form 362 - Alabama Medicaid Referral Form Form 362 - Alabama Medicaid Referral Form Medical
Form 362 - Alabama Medicaid Referral Form Form 362 - Alabama Medicaid Referral Form Medical
Referral Form For Pregnant Women To Receive Dental Care Referral Form For Pregnant Women To Receive Dental Care Medical
Form Doh-799 - Wic Medical Referral Form For Women Form Doh-799 - Wic Medical Referral Form For Women Medical

Related Categories

Parent category: Medical
Download
Go