REFERRAL FORM SERVICING THE LOWER MAINLAND AND FRASER VALLEY FAX : 604-574-3342 PHONE: 604-227-9788 E-MAIL: HealthLinkOutreach@gmail.com PATIENT INFORMATION Patient Name: Date of Birth(yyyy/mm/dd): PHN: Allergies: Address: Phone Number: Cell Number: REASON FOR REFERRAL FAMILY/CAREGIVER INFORMATION: Name: Relationship: Contact Information: PHYSICIAN INFORMATION: Physician: Ph/Fax Number: CASE MANAGER INFORMATION: (CONTACT AT INITIATION OF SERVICE: YesNo) Name: Ph/Fax Number: REFERRAL BY: Name: Title/Position: Phone Number: Fax Number: **PATIENT IS REGISTERED FOR FAIR PHARMACARE? YN**IF NOT, PLEASE DIRECT PATIENT AND/OR FAMILY TO CONTACT: 604-683-7151 TO REGISTER 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)- 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: *Please complete, as able, to provide care planning insights to the Healthlink Outreach team* REASON FOR CURRENT ADMISSION TO HOSPITAL: MEDICAL DIAGNOSES / PERTINENT MEDICAL HISTORY: OTHER RECENT ADMISSIONS TO HOSPITAL?:YesNo (IF YES PLEASE COMPLETE BELOW) HOSPITAL/UNIT: LENGTH OF STAY: DATE ADMITTED: HOSPITAL/UNIT: LENGTH OF STAY: DATE ADMITTED: DOES PATIENT UNDERSTAND ENGLISH?:YesNo PRIMARY LANGUAGE: MOBILITY AIDS: N/ACANEWALKERWHEELCHAIR VISUAL IMPAIRMENT: YesNo HEARING IMPAIRMENT: YesNo DENTURES: YesNo RISK TO CAUSE SELF-HARM? YesNo IF YES, PLEASE EXPLAIN: EXTENDED LEAVE: YesNo RECENT MMSE SCORE: Date: PATIENT IS A&OX3 YesNo IF NO, PLEASE EXPLAIN: **PATIENT MOST: M1M2M3 LOCATION OF DOC. IN PATIENT HOME: **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: MEDICATION INFORMATION: IS PATIENT INSULIN DEPENDENT? YesNo TIME: DOSE: FREQUENCY: ODBIDTIDQID DOES PATIENT REQUIRE ASSISTANCE WITH INSULIN ADMINISTRATION? YesNo HOW DOES THE PATIENT TAKE THEIR ORAL MEDICATION? WHOLECRUSHED PATIENT TAKES THEIR ORAL MEDICATIONS WITH? WATEROTHER: ADDITIONAL COMMENTS/CONCERNS:
