About
Careers
Pharmacy
Contact
FAQ
604-227-9788
Referral Form
SERVICING THE LOWER MAINLAND AND FRASER VALLEY
Patient Information
Patient Name:
*
Phone Number:
*
Patient Address?
Date of Birth(yyyy/mm/dd):
Any Allergies?
Reason For Referral:
Captcha
Pharmacare Information
Is Patient Registered For Fair Pharmacare?
*
Yes
No
Family/Caregiver Information
Care Giver Name?
Relationship:
Contact Information:
Physician Information:
Physician Name:
Physician's Phone Number:
Case Manager Information:
Case Manager Name
Case Manager Phone/Fax Number:
Contact At Initiation Of First Service?
Yes
No
Referred By:
Referral Name:
Referral Title/Position:
Referral Phone Number:
Referral Fax Number:
Pre-Fax Checklist
*Please note that we work with select pharmacies within your community; please fax any referrals and patient prescriptions to the above listed pharmacy fax only*
Patient has 3 or more oral medications, per prescription(s)... (If this is a barrier to referral, please let us know)
Yes
No
Prescription(s) state "DAILY DISPENSE" in handwriting, on each page
Yes
No
Prescription(s) faxed to the pharmacy at: 604-574-3342
Yes
Not Yet
FAX : 604-574-3342
PHONE: 604-227-9788 E-MAIL: HealthLinkOutreach@gmail.com
About
Careers
Pharmacy
Contact
FAQ
