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VIHA specific forms

This folder will contain e-forms specific for VIHA, as requested by Oscar users in this area. More to follow. Stay tuned.
CML MRI Victoria requisition
Requires MRIVic.png in image library.
MRIVic.png
Click to view full-size image before saving with exact title, as above, in image library.
VIHA Pulmonary Function Test requisition
Requires vihapulmonaryfunctiontesting.png.
vihapulmonaryfunctiontesting.gif
Click to view full-size image before saving with exact title, as above, in image library.
VIHA Caesarean Section Pre-Op (v.1)
A two page eForm for pre-operative Caesarian section check-list. Version 1. Upload the HTML file to your e-form library, and BOTH image files to your image library.
VIHA Cardiac Cath/EP/Pacemaker Referral (rev.Dec 2005)
A two page eForm for cardiac catheterization, EP study and Pacemaker inpatient urgent referral. Revised December 2005. Upload the HTML file to your e-form library, and BOTH image files to your image library.
VIHA Cardiac Risk Reduction (rev.Jan 2010)
Cardiac Risk Reduction Program referral form. Revised Jan 2010.
VIHA Central N. Isl. Diabetes Education Centre (rev.Aug 2008)
Central North Island Diabetes Education Centre referral form. Revised Aug 2009.
VIHA CFAU Booking Request (rev.Nov 2002)
CFAU Booking Request. Revised November 2002.
VIHA Heart Function Clinic Referral (v.1)
Heart Function Clinic referral form for Victoria, Nanaimo and Campbell River clinics. Version 1.
VIHA Cystology Histology Specimen (v.1)
Cystology and Histology Specimen eForm for the Royal Jubilee Hospital Diagnostic Treatment Centre.
VIHA Home Oxygen Program Application (rev.Nov 11)
VIHA Home Oxygen Program application form, revised November 26, 2011
VIHA Kidney Clinic Referral (rev.Jan 2006)
VIHA Kidney Care Clinic Referral. Revised Jan 2006.
VIHA Island Lab Services Requisition (v.1)
Lab requisition for Island Lab Services. Version 1.
VIHA Major Pre-Op Gyne Physicians Orders (v.1)
South Island Region physicians prepared orders for pre-operative major gynecological procedures. Version 1.
VIHA Medical Imaging Requisition (rev. Oct 2007)
VIHA Medical Imaging Requisition. Revised Oct 2007.
VIHA Minor Pre-Op Gyne Physicians Orders (v.1)
South Island Region physicians prepared orders for pre-operative minor gynecological procedures. Version 1.
VIHA OR Booking Form (v.1)
Regional surgical booking request form. Version 1.
VIHA Outpatient Adult Diabetes Services (v.1)
Outpatient adult diabetes services referral form. Version 1.
VIHA Pre-Op History and Physical with ASA Classification, 2 pages (rev. May 2006)
A two page eForm for pre-operative patient history and physical. Second page includes ASA Classification. Revised May 2006. Upload the HTML file to your e-form library, and BOTH image files to your image library.
VIHA Pulmonary Function Testing (rev. Sept 2007)
Royal Jubilee Hospital requisition for outpatient pulmonary function testing. Revised Sept 2007.
VIHA Stroke Rapid Assessment Referral (v.1)
Victoria General Hospital Stroke Rapid Assessment Unit referral form. Version 1.
VIHA Ultrasound and Vascular Lab (v.1)
See updated Version 2 (below). Original ultrasound and vascular lab request form (version 1).
VIHA VGH Maternity Admission Form (rev. March 2011)
Victoria General Hospital maternity admission information form. Revised March 2011.
VIHA Ultrasound and Vascular Lab (v.3)
Replaces Version 1 & 2. Ultrasound and vascular lab request form (version 3).
VIHA Colposcopy Clinic (v.1)
RJH Colposcopy Clinic referral form for Victoria. Version 1.
VIHA Consent for Blood Products (v.1)
VIHA consent form for blood products. Version 1.
VIHA Induction of Labour (v.1)
Induction of Labour Booking Form. Version 1.
VIHA Bone Density 2015
Updated March 2016 at the request of the Qudara Island Medical Clinic now pulls MSP number instead of CPSID Number - Update provided by NERD BC. --- New form created by VIHA January 2015. Eform supplied by Patti at OSCARWest
VIHA lab services eForm
Update March 2016 - the form was pulling the CPSID number instead of the MSP number for the provider - Corrected by NERD BC. From Gunther - Hi guys, I made a VIHA lab services eForm with floating side menu. Anyone wanna beta test? Gunther
VIHA Healthy Heart Referral Form
From Patti Roger Kirkpatrick contributed on behalf of the Cook-Quadra Medical Clinic in Victoria. At your next opportunity could you please add this to the VIHA section of the eforms library? Referral for Electrodiagnostic Services VIHA Healthy Heart Referral
VIHA Colposcopy Clinic form
From Patti Roger Kirkpatrick - contributed on behalf of the Cook-Quadra Medical Clinic in Victoria.
VIHA Colposcopy form
From Patti Rodger Kirkpatrick - Hi John Enjoy your holiday and ignore this email till you return. The VIHA Colposcopy form on the OSCAR website doesn't save as the form is missing the type="text" line throughout the code. Can you please replace it with the zip file attached. (I've been fixing it at too many sites......)
VIHA MRI Requisition Aug2012 version
Oakville Cardiology Referral and Lab Forms
For those Oakville docs, Here’s the 2nd part of the eForm request. JohnY Thanks to JohnR, now have figured out why the checkGender script sometimes works and sometimes not. Seems that every referenced name has to actually exist in the eForm. Sometimes a leftover name appears, because the eForm was adapted from a previous one, where the name was needed. You’ve got sharp eyes, JohnR! Here’s the corrected version. JohnY OK - here’s my initial stab at the eForm. I don’t know what the database tag for user’s eMail address - so you’ll have to plug that in yourself. I found that the gender checker doesn’t work, unless the script is the first one called with the “onload” function. Can someone confirm this - as I know other’s have expressed problems with it before. I’ve modified the background - so the spacing for some of the items has been Oscarized! JohnY I've received a request from the Oakvillle Cardiologists group to have their diagnostic test requisition and their consultation request form converted to an eForm for sharing in the OSCAR community. See attached PDFs. Anyone keen on tackling this one? Gunther
VIHA Outpatient Medical Imaging Req Dec 2013
The folks at VIHA (recently renamed as "Island Health"), have come up with a new outpatient medical imaging requisition that VIHA doctors are now required to use. Attached is my eFormed version. I've made two editions, one for Windows with larger checkboxes, and one for Mac/Linux desktops with regular checkboxes. Files attached. Please report bugs. Gunther
MedPro_Respiratory_Island
Donated By Nerd BC and MedPro
Exercise is Medicine Canada referral form
Pacific Sleep Care referral eForm for Campbell River
Updated November 29 2014. I was asked to make a "pretty" eForm for the Pacific Sleep Care branch office in Campbell River. Please find attached. I pilfered the x-box code from one of JohnY's eForms (thanks John). Gunther.
Bariatric Surgery Referral Form for Island Health
Referral to Bariatric Program, Royal Jubilee Hospital Victoria BC. Has conversion from imperial to metric for height and weight, calculates BMI.
Vancouver Island Health Bone Density Requisition 2015
Commissioned by Dr. Chew and Dr. Fast. Created by Nerd BC.
Victoria Gastroenterology Referral eform 2015
Provided by NERD BC.
VIHA Adult Preoperative Clinical Order Set
Created by NERD BC
VIHA Non-Emergency Colon Resection Pre-Operative Pathway Orders
Provided by NERD BC and Summit Surgical Associates
Vancouver Island Health - Mental Health and Substance use - Lady Minto Hospital Foundation referral form
Created by NERD BC commissioned by Kings Lane Medical Clinic (Salt Spring Island)
Chronic Migraine Consultation Request 2015
Referral to Dr. Corrie Graboski for chronic migraines, From NERD BC and Medicine Cabinet
VIHA stroke rapid assessment unit, ACVS form
For referral to the VIHA Stroke Rapid Assessment Unit. Created by NERD BC and was commissioned by The Medicine Cabinet in Nanaimo.
VIHA Shapedown BC - BC Physician Referral eForm
VIHA Shapedown BC - BC Physician Referral eForm which was commissioned by The Medicine Cabinet in Nanaimo, and Created by NERD BC.
VIHA Seniors Health Referral eForm November 2015
This form was commissioned by Quadra Island Medical Clinic on Quadra Island. The changes to the form are reflected in the telephone and fax number. Created By NERD BC
Outpatient IV Iron order form Island Health
From Gunther - Another day, another form to add to the pile. This one is VIHA (Island Health) specific and has to be completed before Iron Sucrose infusion can be ordered at medical day care. Apparently there has been concern about the exponential increase in Iron Sucrose IVI orders and the form is a cost containment measure. Attached is the eForm for your testing and bug fixing pleasure. I pilfered JohnR's script for the multiple freeform signatures on the form. Because it is a multi page form I moved the print / submit buttons into a floating side menu. I left the original bottom buttons in comment tags in case that's to fancy for you. > > Cheers > Gunther
NRGH Pulmonary Function Lab and Community Respiratory Care Centre Requisition
Created by NERD BC and commissioned by The Medicine Cabinet in Nanaimo
Nanaimo Integrated Health Network Team Enrollment Form
Created by NERD BC for the Medicine Cabinet February 2016 - Enrollment form for the Nanaimo Integrated Health Network Team
Campbell River Mental Health and Substance Use referral form February 2016
Referral form for the Campbell River Mental Health and Substance Use program created February 2016 by NERD BC for Quadra Island Medical Clinic
Early Pregnancy Assessment Unit 2016
Eform created by NERD BC for Grow Health Victoria
VIHA Echocardiogram Req 2016
This form was created by NERD BC
Child Youth and Family Mental Health Services VIHA
This form: Child and Youth Mental Health Services eForm, was commissioned by the Medicine Cabinet in Nanaimo, and created By NERD BC
Nanaimo Regional General Hospital Surgical Wound Clinic Referral eForm 2016
donated by Mike Thompson of NERD BC
VIHA_Integrated Community Services - Central Island 2016
Created by NERD BC
NRGH Pain Clinic Referral Form 2016
Created by NERD BC
Central_Vancouver Island Foot and Ulcer Protection Clinic 2016
Created by NERD BC
VIHA Oceanside Referral Form 2016
Created by NERD BC
VIHA_Central/North Island Diabetes Education Centre Referral eForm 2016
This form was created by NERD BC.
Comox Valley Mental Health & Substance Use Referral 2016
Stephanie from the Bridge Medical clinic in the Campbell River area has made a new referral eForm for the Comox Valley Mental Health and Substance use agency.
Campbell River Maternity Clinic Referral form
Created by the Campbell River Maternity Clinic - updated 2017
St Joseph's Medical Imaging Vancouver Island 2016
Created by Stephanie Friesen of The Bridge Medical Clinic
Tilray Medical Requisition Form Vancouver Island 2016
Created by Stephanie Friesen of the Bridge Medical Clinic
Nanaimo Disability Resource Centre Parking permit application 2017
Form Updated by NERD BC - commissioned by the Sayward Primary Health Clinic.
Pacific Sleep Care 2017
NERD BC has provided the following forms: Pacific Sleep Care eForms for the Courtenay, Duncan and Nanaimo locations to share with the OSCAR community. They have been commissioned by Simone at Pacific Sleep Care.
VIHA_Atrial Fibrillation Clinic
Created by NERD BC, Commissioned by Urgent Medical Assessment Clinic Victoria.
VIHA_Bone Marrow Biopsy
Created by NERD BC, Commissioned by Urgent Medical Assessment Clinic Victoria.
VIHA_Adult IV Iron therapy 2017
Edited by John Yap - I think VIHA users may find the tidbits from the FHA Iron infusion form helpful - i.e. autopopulation of Hgb, Ferritin, and TSAT. You may need to ensure these results are properly mapped to your measurements to be fully functional. Created by Nerd BC, commissioned by Urgent Medical Assessment Clinic Victoria.
MedPro Respiratory - Vancouver Island 2017
Created by NERD BC and Commissioned by George Louvros, MedPro Respiratory Care.
VIHA_Young Adult Collaborative Care 2017
Young adult Collaborative Care Vancouver Island Health 2017
VIHA Hearing Services 2017
Referral for Vancouver Island Health Authority Hearing Services.
VIHA Mental Health and Substance Use 2017
This is an update to the 2008 and 2011 versions.
Island CPAP - Services and Supplies 2017
OSA Testing
ViHA Echocardiography Requisition 2017
This form replaces the 2016 version.
VIHA Echo Cardiography Requisition 2017
Island Health / Vancouver Island Health Authority Echocardiography Requisition 2017
Island Health - Child and Family Health Unit Assessment Form 2018
This form has been created by Grow Health in Victoria. It has been tested on Firefox 17 and 52.
Vancouver Island Health's Community Access Centres referral form 2018
Updated - 2018-Jun-28 10:11 Oceanside community button added There are now 4 forms in 1 with 4 buttons to switch between communities-you will need to delete the old form to update the new form. Update May 14th 2018 - I have made the second page (instructions for filling out the form) into a side menu that does not print. I have amalgamated the 3 forms into 1 form with buttons to switch between the three areas. I have added a link to the MOST form and to the lab display. Other minor code updates. John Robertson ----- Form Name: Island Health Referral Form Description:This form is used to refer to Island Health's Community Access Centres (Community Intake) for all community-based services provided through Island Health. ---- Key words needed:Referral - Nanaimo, Referral-Cowichan, Referral - Victoria, Community Access, Intake ----

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