REFERRAL FORM

SERVICING THE LOWER MAINLAND AND FRASER VALLEY

FAX : 604-574-3342

PHONE: 604-227-9788 E-MAIL: HealthLinkOutreach@gmail.com

PATIENT INFORMATION

(CONTACT AT INITIATION OF SERVICE: YesNo)

**PATIENT IS REGISTERED FOR FAIR PHARMACARE? YN
**IF NOT, PLEASE DIRECT PATIENT AND/OR FAMILY TO CONTACT: 604-683-7151 TO REGISTER


- Patient has 3 or more oral medications, per prescription(s) (If this is a barrier to referral, please let us know)- Prescription(s) state “DAILY DISPENSE” in handwriting, on each page- If in hospital- Projected discharge- Prescription(s) faxed to the pharmacy at: 604-574-3342

ADDITIONAL PATIENT DETAILS:

YesNo (IF YES PLEASE COMPLETE BELOW)
YesNo

N/ACANEWALKERWHEELCHAIR
YesNo
YesNo
YesNo

YesNo
YesNo
YesNo
M1M2M3

**IS PATIENT KNOWN TO BE AGGRESSIVE OR A RISK TO OTHERS ATTENDING HOME: YesNo
**IF YES, PLEASE EXPLAIN TO ALLOW FOR SAFE VISITATION BY HLO NURSES:


YesNo
ODBIDTIDQID
YesNo

WHOLECRUSHED

WATEROTHER: