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BC NeuroPsychaitry Referral

HTML icon BC-NeuroPsyc-Referral-Form.html — HTML, 25 kB (26360 bytes)

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<html>
<head>
<title>BC NeuroPsychiatry Program</title>

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<body onload="">

<div id="chkCanvas" style="position:absolute; left:0px; top:0px; width:750; height:1000;" onmouseover="putInBack();"></div>

<form method="post" action="" name="FormName" id="FormName" >

<div style="position: absolute; left:45px; top:4px; font-size:12px;font-family:arial; font-style:italic; ">

<span>Return this page to the BCNP</span>

</div>

<div style="position: absolute; left:550px; top:4px; font-size:12px;font-family:arial; font-style:italic; ">

<span>Referral Form 8/12/10</span>

</div>


<div style="position: absolute; left:240px; top:42px; font-size:15px;font-family:arial; font-weight:bold; ">

<span>BC NEUROPSYCHIATRY PROGRAM</span>

</div>

<div style="position: absolute; left:50px; top:72px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>All referrals are screened at our weekly triage meeting.</span>

</div>

<div style="position: absolute; left:440px; top:72px; font-size:14px;font-family:arial; font-weight:bold; text-decoration:underline; ">

<span>Please insure that all requested</span>

</div>

<div style="position: absolute; left:50px; top:92px; font-size:14px;font-family:arial; font-weight:bold; text-decoration:underline; ">

<span>information is attached.</span>

</div>

<div style="position: absolute; left:220px; top:92px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>Incomplete information will delay processing the referral.</span>

</div>

<div style="position: absolute; left:50px; top:121px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>Date of Referral:</span>

</div>

<input name="Date" id="Date" type="text" class="noborder" style="position:absolute; left:189px; top:112px; width:234px; height:26px; font-family:sans-serif; 

font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=today>

<div style="position: absolute; left:50px; top:154px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>Name of Patient:</span>

</div>

<input name="PtName" id="PtName" type="text" class="noborder" style="position:absolute; left:189px; top:145px; width:328px; height:26px; font-family:sans-

serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=first_last_name>

<div style="position: absolute; left:565px; top:154px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>Gender</span>

</div>

<input name="Gender" id="Gender" type="text" class="noborder" style="position:absolute; left:622px; top:145px; width:40px; height:26px; font-family:sans-

serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=sex>

<div style="position: absolute; left:98px; top:187px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>Age:</span>

</div>

<input name="Age" id="Age" type="text" class="noborder" style="position:absolute; left:141px; top:182px; width:47px; height:26px; font-family:sans-serif; 

font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=age>

<div style="position: absolute; left:204px; top:187px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>Date of Birth:</span>

</div>

<input name="DOB" id="DOB" type="text" class="noborder" style="position:absolute; left:299px; top:182px; width:127px; height:26px; font-family:sans-serif; 

font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=dob>

<div style="position: absolute; left:438px; top:187px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>PHN:</span>

</div>

<input name="PHN" id="PHN" type="text" class="noborder" style="position:absolute; left:476px; top:182px; width:184px; height:26px; font-family:sans-serif; 

font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=hinc>

<div style="position: absolute; left:98px; top:220px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>Telephone Number:</span>

</div>

<div style="position: absolute; left:237px; top:220px; font-size:14px;font-family:arial; font-weight:bold; text-decoration:underline; ">

<span>(h)</span>

</div>

<input name="HomePhone" id="HomePhone" type="text" class="noborder" style="position:absolute; left:257px; top:213px; width:166px; height:26px; font-

family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  

oscarDB=phone>

<div style="position: absolute; left:472px; top:220px; font-size:14px;font-family:arial; font-weight:bold; text-decoration:underline; ">

<span>(w)</span>

</div

<input name="WorkPhone" id="WorkPhone" type="text" class="noborder" style="position:absolute; left:494px; top:213px; width:168px; height:26px; font-

family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  

oscarDB=phone2>

<div style="position: absolute; left:98px; top:253px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>Address:</span>

</div>

<input name="PtAddress" id="PtAddress" type="text" class="noborder" style="position:absolute; left:186px; top:246px; width:472px; height:26px; font-

family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  

oscarDB=addressline>


<div style="position: absolute; left:50px; top:286px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>Referring Physician:</span>

</div>


<input name="ReferringPhysician" id="ReferringPhysician" type="text" class="noborder" style="position:absolute; left:195px; top:278px; width:237px; 

height:26px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-

color:white;"  oscarDB=doctor>

<div style="position: absolute; left:472px; top:286px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>Billing #:</span>

</div>

<input name="BillingNumber" id="BillingNumber" type="text" class="noborder" style="position:absolute; left:558px; top:278px; width:100px; height:26px; font-

family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:transparent;"  

oscarDB=doctor_ohip_no>

<div style="position: absolute; left:98px; top:319px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>Telephone:</span>

</div>

<input name="ClinicPhone" id="ClinicPhone" type="text" class="noborder" style="position:absolute; left:180px; top:311px; width:102px; height:26px; font-

family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; text-decoration:underline; background-

color:white;"  oscarDB=clinic_phone>

<div style="position: absolute; left:285px; top:319px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>Fax:</span>

</div>

<input name="ClnicFax" id="ClnicFax" type="text" class="noborder" style="position:absolute; left:315px; top:311px; width:106px; height:26px; font-

family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;"  

oscarDB=clinic_fax>

<div style="position: absolute; left:425px; top:319px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>Dr.'s Private Line</span>

</div>

<input name="PrivateLine" id="PrivateLine" type="text" class="noborder" style="position:absolute; left:553px; top:311px; width:104px; height:26px; font-

family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;" value="">

<div style="position: absolute; left:98px; top:352px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>Address:</span>

</div>

<input name="ClinicAddress" id="ClinicAddress" type="text" class="noborder" style="position:absolute; left:162px; top:345px; width:495px; height:26px; font-

family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:transparent;"  

oscarDB=clinic_addressLineFull>

<div style="position: absolute; left:238px; top:370px; font-size:9px;font-family:arial; font-weight:normal; ">

<span>Street</span>

</div>

<div style="position: absolute; left:472px; top:370px; font-size:9px;font-family:arial; font-weight:normal; ">

<span>City</span>

</div>

<div style="position: absolute; left:565px; top:370px; font-size:9px;font-family:arial; font-weight:normal; ">

<span>Postal Code</span>

</div>

<input name="FP" id="FP" type="checkbox" style="position:absolute; left:94px; top:394px; ">

<div style="position: absolute; left:120px; top:397px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>Family Physician</span>

</div>


<input name="Psy" id="Psy" type="checkbox" style="position:absolute; left:235px; top:394px; ">


<div style="position: absolute; left:254px; top:397px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>Psychiatrist</span>

</div>


<input name="Neuro" id="Neuro" type="checkbox" style="position:absolute; left:335px; top:394px; ">

<div style="position: absolute; left:356px; top:397px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>Neurologist</span>

</div>


<input name="Other" id="Other" type="checkbox" style="position:absolute; left:437px; top:394px; ">

<div style="position: absolute; left:458px; top:397px; font-size:14px;font-family:arial; font-weight:bold; ">

<span>Other</span>

</div>


<input name="ReferralOther" id="ReferralOther" type="text" class="noborder" style="position:absolute; left:507px; top:390px; width:151px; height:24px; font-

family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;" value="">

<div style="position: absolute; left:50px; top:426px; font-size:16px;font-family:arial; font-weight:bold; ">

<span>Goal of Referral:</span>

</div>

<textarea name="Goal" id="Goal" class="noborder" style="position:absolute; left:175px; top:422px; width:483px; height:64px; font-family:sans-serif; font-

style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;" ></textarea>


<table width="676" height="72" style="border-style:solid; border-width:3;  font-size:14px;font-family:arial; font-weight:bold; position: absolute; top:490px; 

left:35px; ">
<tr>
	<td align="left" colspan=7>
		Neurobehavioural Inventory Completed?
	</td>
 
        <td align="left" colspan=1>
		<input name="Inventory" id="Inventory" type="checkbox">
	</td>

	<td align="left" colspan=2>
		Unsettled Medical-Legal case
	</td>

        <td>
	        Yes
	</td>
	<td>
	        <input name="MedicalLegal" id="MLYes" value="Yes" type="radio" />
        </td>

	<td>
			     
	        No
        </td>
        <td>  
                <input name="MedicalLegal" id="MLNo" value="No" type="radio" />
        </td>



</tr>

<tr>
	<td colspan=7>
		Is the patient supportive of this referral?
	</td>


 

        <td align="left" colspan=1></td>

	<td align="left" colspan=2>
		Unsettled ICBC case................
	</td>


        <td>
	        Yes
	</td>
	<td>
	        <input name="ICBC" id="ICBCYes" value="Yes" type="radio" />
        </td>

	<td>
			     
	        No
        </td>
        <td>  
                <input name="ICBC" id="ICBCNo" value="No" type="radio" />
        </td>


</tr>

<tr>
	<td colspan=1></td>


        <td align="center" colspan=1>

        <input name="SupportiveY" id="SupportiveY" type="checkbox" >

        </td>

        <td align="left" colspan=1>

        Yes

        </td>


        <td align="center" colspan=1>

        <input name="SupportiveN" id="SupportiveN" type="checkbox" >

        </td>


        <td align="left" colspan=1>

        No

        </td>



        <td align="center" colspan=1>

        <input name="SupportiveNA" id="SupportiveNA" type="checkbox" >

        </td>


        <td align="left" colspan=1>

        Not Aware

        </td>



        <td align="left" colspan=1></td>

	<td align="left" colspan=2>
		Worksafe BC case....................
	</td>


        <td>
	        Yes
	</td>
	<td>
	        <input name="worksafe" id="WSYes" value="Yes" type="radio" />
        </td>

	<td>
			     
	        No
        </td>
        <td>  
                <input name="worksafe" id="WSNo" value="No" type="radio" />
        </td>



</tr>

</table>


<div style="position: absolute; left:57px; top:573px; font-size:14px;font-family:arial; font-weight:bold; font-style:italic; text-decoration:underline; ">

<span>We do NOT accept patients into our Outpatient Program who have active medical/legal cases.</span>

</div>

<div style="position: absolute; left:130px; top:591px; font-size:14px;font-family:arial; font-weight:bold; font-style:italic; text-decoration:underline; ">

<span>Also, we cannot accept referrals specifically for neuropsychology testing.</span>

</div>

<div style="position: absolute; left:53px; top:614px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Patient's clinical circumstances are best suited for(see attached):</span>

</div>

<div style="position: absolute; left:558px; top:614px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Outpatient Clinic</span>

</div>

<input name="Outpt" id="Outpt" type="checkbox" style="position:absolute; left:680px; top:611px; ">

<div style="position: absolute; left:548px; top:632px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Inpatient Program</span>

</div>


<input name="InPt" id="InPt" type="checkbox" style="position:absolute; left:680px; top:629px; ">

<div style="position: absolute; left:275px; top:650px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Fraser Health Authority Neuropsychiatry Outpatient Clinic</span>

</div>


<input name="FHANOC" id="FHANOC" type="checkbox" style="position:absolute; left:680px; top:647px; ">

<div style="position: absolute; left:50px; top:679px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Patient's</span>

</div>

<div style="position: absolute; left:112px; top:679px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; text-decoration:underline; ">

<span>current and ongoing care</span>

</div>

<div style="position: absolute; left:295px; top:679px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>provided by (check all that apply):</span>

</div>

<div style="position: absolute; left:98px; top:697px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Family Physician</span>

</div>

<input name="CurrentFP" id="CurrentFP" type="checkbox" style="position:absolute; left:280px; top:695px; ">

<div style="position: absolute; left:330px; top:697px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Name:</span>

</div>

<input name="CurrentFPName" id="CurrentFPName" type="text" class="noborder" style="position:absolute; left:375px; top:696px; width:189px; height:16px; font-

family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;" value="">

<div style="position: absolute; left:98px; top:715px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Psychiatrist</span>

</div>

<input name="CurrentPsy" id="CurrentPsy" type="checkbox" style="position:absolute; left:280px; top:713px; ">

<div style="position: absolute; left:330px; top:715px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Name:</span>

</div>

<input name="CurrentPsycName" id="CurrentPsycName" type="text" class="noborder" style="position:absolute; left:375px; top:714px; width:189px; height:16px; 

font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;" value="">

<div style="position: absolute; left:98px; top:733px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Neurologist</span>

</div>

<input name="CurrentNeuro" id="CurrentNeuro" type="checkbox" style="position:absolute; left:280px; top:731px; ">

<div style="position: absolute; left:330px; top:733px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Name:</span>

</div>

<input name="CurrentNeuroName" id="CurrentNeuroName" type="text" class="noborder" style="position:absolute; left:375px; top:732px; width:189px; height:16px; 

font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;" value="">

<div style="position: absolute; left:98px; top:751px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Mental Health Team</span>

</div>

<input name="CurrentMHT" id="CurrentMHT" type="checkbox" style="position:absolute; left:280px; top:749px; ">

<div style="position: absolute; left:330px; top:751px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Name:</span>

</div>

<input name="CurrentMHTName" id="CurrentMHTName" type="text" class="noborder" style="position:absolute; left:375px; top:750px; width:189px; height:16px; 

font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;" value="">

<div style="position: absolute; left:98px; top:769px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Other</span>

</div>

<input name="CurrentOther" id="CurrentOther" type="checkbox" style="position:absolute; left:280px; top:767px; ">

<div style="position: absolute; left:330px; top:769px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Name:</span>

</div>

<input name="CurrentOtherName" id="CurrentOtherName" type="text" class="noborder" style="position:absolute; left:375px; top:768px; width:189px; height:16px; 

font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;" value="">


<div style="position: absolute; left:50px; top:799px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Please attach all the documents listed below:</span>

</div>

<div style="position: absolute; left:98px; top:817px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Previous neurological consultation</span>

</div>


<input name="PreviousNeuroConsult" id="PreviousNeuroConsult" type="checkbox" style="position:absolute; left:422px; top:814px; ">

<div style="position: absolute; left:98px; top:835px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Previous psychiatric consultation</span>

</div>

<input name="PreviousPsyConsult" id="PreviousPsyConsult" type="checkbox" style="position:absolute; left:422px; top:832px; ">

<div style="position: absolute; left:98px; top:853px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Previous neuro-imaging reports (CT, MRI)</span>

</div>

<input name="PreviousImg" id="PreviousImg" type="checkbox" style="position:absolute; left:422px; top:850px; ">

<div style="position: absolute; left:98px; top:871px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Previous neuropsychological testing</span>

</div>

<input name="PreviousTest" id="PreviousTest" type="checkbox" style="position:absolute; left:422px; top:868px; ">

<div style="position: absolute; left:98px; top:889px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Recent laboratory data</span>

</div>

<input name="LabData" id="LabData" type="checkbox" style="position:absolute; left:422px; top:886px; ">




<div style="position: absolute; left:50px; top:922px; font-size:14px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Return to:</span>

</div>

<div style="position: absolute; left:144px; top:921px; font-size:15px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>BC NEUROPSYCHIATRY PROGRAM</span>

</div>

<div style="position: absolute; left:144px; top:939px; font-size:15px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>UBC Hospital, 2255 Westbrook Mall, Vancouver, B.C. V6T 2A1</span>

</div>

<div style="position: absolute; left:144px; top:957px; font-size:15px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Fax: (604) 822-7491</span>

</div>

<div style="position: absolute; left:420px; top:957px; font-size:15px;font-family:arial; font-weight:bold; font-style:normal; ">

<span>Tel: (604) 822-9758</span>

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