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Clinical Referral

Clinical Referral

Please fill out the fields below to the best of your knowledge and click submit at the bottom once completed.

Referral For

Name

First Last

Preferred Name

Date of Birth

Month

Day

Year

Health Card Number

Version Code

Gender

Primary Language

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Current Location

If currently in hospital, which hospital?

Anticipated Hospital Discharge Date

MM slash DD slash YYYY

Client has consented to Hospice Referral

No

Yes

Unknown

Urgency of Response

Primary Referral Contact

Name

First Last

Relationship

Home Phone

Mobile Phone

Substitute Decision Maker

Name

First Last

Relationship

Home Phone

Mobile Phone

Diagnosis

Metastatic spread, if malignant

Other relevant diagnosis / symptoms

Past Medical History

If cancer diagnosis, ongoing treatment?

Individual Aware of Diagnosis

Yes

No

Unknown

Date of Diagnosis

Month

Day

Year

Prognosis

PPS

DNR

Discussed and Signed

Discussed but Not Signed

Not Discussed

Rcvd on Admission

Medical Allergies

Infection Control

Please specify

Current Community Services

Current Care Needs

Please specify

Care Needs, Detailed

Pharmacy Information

Name

First Last

Phone

Additional Information

Referring Individual Information

Name

First Last

Phone

Referring Physician/MRP

Name

First Last

Phone

Email

Contact Information

Oak Ridges Hospice of Durham Ltd.
1722 Scugog St.
Port Perry, ON L9L 1E2

Charitable Registration Number 81051 1329 RR0001

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Land Acknowledgement

We respectfully acknowledge that the Central East Region is located onTreaty 20 Michi Saagiig Territory, collectively known as the WilliamsTreaties First Nations; which includes Curve Lake, Hiawatha, Alderville,Scugog Island, Rama, Beausoleil and Georgina Island First Nations. We offer our gratitude to the Indigenous peoples for their care and teachings about our relationship to Mother Earth and all living things. Weare grateful for the opportunity provided by this special place we all share and we thank all the generations of people who have taken care of this land for millennia. May our partnerships with the First Nation, Inuit, Métis and urbanIndigenous People help us to work together to provide the best care possible to our residents, their families and our community.

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