Download Physician referral form (word document)

HELMCKEN PAIN CLINIC – INTERVENTIONAL PAIN MANAGEMENT
211 – 284 Helmcken Rd, Victoria BC, Canada V9B 1T2
Appts: 250-595-5905 Fax: 250-595-5907
www.helmckenpainclinic.com
(Please mail if sending more than 5 pages)
Date
Patient Information
Referring Physician
Name
DOB
MSP
(WCB#)
Address/PC
Phone#
Alt Phone #
Name
MSP#
Address
Phone#
Fax#
Family Physician
Fax#
Patient to See
☐ Dr. D. Vincent MD FRCPC ABDA
☐ Dr. B. MacNicol MD FRCPC CHSE
Duration of Symptoms
Body Part
______________________
☐ FIRST AVAILABLE
☐ <1 mo ☐ 1-6 mo ☐ 6-12 mo ☐ 12-24 mo ☐ 24+ mo
☐ Low back ☐ Upper Back ☐ Neck ☐ Shoulder ☐ Head
☐ Arm
☐ Leg
☐ Other
________________________________________________________
Reason for Referral (include relevant symptoms, physical findings and treatment to date) (☐ Letter attached)
(☐ This is or may be CRPS – complex regional pain syndrome, ☐ post-herpetic neuralgia , or ☐ other neuralgia)
Past Medical & Surgical History (☐ Letter attached)
Medications (☐ Letter attached)
Allergies (☐ Letter attached)
Has the patient had injections in the past? (List attached ☐)
Has the patient been through a comprehensive chronic pain
program such as the RJH or NRGH?
☐ Yes ☐ No
Have appropriate X-Rays / Diagnostic tests been obtained / ordered?
☐
☐
Yes – results attached
No – Please indicate exceptional circumstances in the space below
Upon review, receipt of referral will be confirmed via fax to referring physician’s office. An approximate wait for the appointment
will be indicated. Patients will be contacted directly to schedule appointments. Please ensure that your patient completes the brief
pain inventory (attached) and brings it with him/her to his/her first appointment.