1

Complete form as fully as you can

Please print the form and fill it out according to the instructions below:

If you are a community nurse or physician's office:

Please provide us with as much of the requested documentation as you have in order to assist us with triage. Please note the boxes on the bottom half of the referral form for a list of what information we require for different referral types.

If you are a community agency or support worker booking on behalf of a client: 

Please fill out as much information as you can on our referral form and let us know which physician's office, community nurse, or hospital we can obtain your client's medical history from. 

2

Fax the referral and documentation

Please fax the referral and all attached documentation to our confidential fax at (604) 875-3063.