Clinical Referral

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

Referral For
First Name:

Last Name:

Preferred Name:

Date of Birth: UnspecifiedJANFEBMARAPRMAYJUNJULAUGSEPOCTNOVDEC Unspecified12345678910111213141516171819202122232425262728293031 Unspecified20222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901

Health Card Number:

Version Code:

Gender: UnspecifiedFemaleMaleOtherTransgenderUndisclosedUnknownUnspecified

Primary Language: EnglishFrenchUnspecifiedAfrikaansArabicBelarusianCalabreseCantoneseCatalanCzechDutchEnglishEsperantoEsperantoEstonianGermanGreekGujaratiHindiHungarianItalianJapaneseKoreanLithuanianMandarinMarathiPolishPortuguesePunjabiPushtoRomanianRussianSlovakSpanishSwahiliTamilThaiUkrainianUrduVietnameseUnspecified

Home Address:

City:

Postal Code:

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Current Location: UnspecifiedERFamilyHomeHospiceHospitalLTCOutreach - EROutreach - FamilyOutreach - HomeOutreach - HospiceOutreach - HospitalOutreach - LTCRetirement HomeShelterUnknown

If currently in hospital, which hospital?

Anticipated Hospital Discharge Date:

Client has consented to Hospice Referral:UnspecifiedNoYesUnknown

Urgency of Response:

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Primary Referral Contact:
First Name:

Last Name:

Relationship:

Home Phone:

Mobile Phone:

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Substitute Decision Maker
First Name:

Last Name:

Relationship:

Home Phone:

Mobile Phone:

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Diagnosis:



Metastatic spread, if malignant:


Other relevant diagnosis / symptoms:


Past Medical History:


If cancer diagnosis, ongoing treatment? :


Individual Aware of Diagnosis: UnspecifiedYesNoUnknown

Date of Diagnosis:

Prognosis: UnspecifiedUnavailable1 Week2 Weeks3 Weeks1 Month2 Months3 Months4 Months5 Months6 Months1 Year2 Years

PPS: Unspecified102030405060708090100

DNR: UnspecifiedDiscussed and SignedDiscussed but Not SignedNot DiscussedRcvd on Admission

Medical Allergies:


Infection Control: NoneC-DIFF+ - ContactCOVID-19+ - Airborne,Droplet,ContactChicken Pox - AirborneESBL+ - ContactHIV+ - ContactHepatitis+Lice - ContactMRSA+ - ContactOther - AirborneOther - ContactOther - DropletOther - SpecifyOther - StandardRespiratory - DropletScabies - ContactShingles - AirborneTB - AirborneVRE+ - Contact

Current Community Services: Community Care DurhamDurham Hospice WhitbyFamily Health Team Port PerryHome and Community Services

Current Care Needs: Central Line(s)Chest Tube(s)DialysisEnternal FeedsFeeding TubeHydration IVHydration SCInfusion Pump(s)Ostomy CareOxygenP.I.C.C. Line(s)ParacentesisPortaCathPressure Ulcer(s)Therapeutic SurfaceThoracentesisTracheostomyTransfusionWound CareOther

Care Needs, Detailed:

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Pharmacy Information:
First Name:

Last Name:

Phone:

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Additional Information:

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Referring Individual Information

First Name:

Last Name:

Phone:

Fax:

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Referring Physician/MRP

First Name:

Last Name:

Phone:

Fax:

Email: