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Orthopaedic Cerebral Palsy Clinic - BC Children's …

Orthopaedic Cerebral Palsy Clinic Orthopaedics: Tel: 604 875 2345 ext 3187 / Fax: 604 875 2275 Orthopaedic CP Clinic Referral Form To be completed by referring physician Referral will NOT be processed if incomplete DATE OF REFERRAL Day_____ Month_____ Year_____ PATIENT INFORMATION Last Name: _____ Fist Name_____ DOB_____ PHN: _____ Sex: M F Address: _____ Parent/Legal guardian: _____ Relationship:_____ Phone:_____ Alternate:_____ Email:_____Is the child in the care of the Ministry (MCFD)?

Orthopaedic Cerebral Palsy Clinic Orthopaedics: Tel: 604 875 2345 ext 3187 / Fax: 604 875 2275 www.bcchildrens.ca/orthocpclinic Orthopaedic CP Clinic Referral Form ...

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  Children, Clinic, Cerebral, Palsy, Orthopaedic, Orthopaedic cerebral palsy clinic

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Transcription of Orthopaedic Cerebral Palsy Clinic - BC Children's …

1 Orthopaedic Cerebral Palsy Clinic Orthopaedics: Tel: 604 875 2345 ext 3187 / Fax: 604 875 2275 Orthopaedic CP Clinic Referral Form To be completed by referring physician Referral will NOT be processed if incomplete DATE OF REFERRAL Day_____ Month_____ Year_____ PATIENT INFORMATION Last Name: _____ Fist Name_____ DOB_____ PHN: _____ Sex: M F Address: _____ Parent/Legal guardian: _____ Relationship:_____ Phone:_____ Alternate:_____ Email:_____Is the child in the care of the Ministry (MCFD)?

2 Yes No If yes, SW:_____ Phone: _____ Is an interpreter needed: Yes No Language: _____ REFERRING PHYSICIAN INFORMATION Name (PRINT): First_____ Last_____ MSP #_____ Phone:_____ Fax:_____ OTHER PHYSICIANS INVOLVED IN CARE Family Doctor: _____ Phone: _____ Fax: _____ Pediatrician: _____ Phone: _____Fax: _____ 4500 Oak Street, Vancouver, BC V6H 3N1 Phone: (604)875-2345 ext 3187 Fax: (604) 875-2275 Page 1 of 2 Orthopaedic Cerebral Palsy Clinic Orthopaedics: Tel: 604 875 2345 ext 3187 / Fax: 604 875 2275 Orthopaedic CP Clinic Referral Form To be completed by referring physician Referral will NOT be processed if incomplete **ALL HIP REFERRALS MUST HAVE A RECENT A/P PELVIS XRAY** OTHER SPECIALISTS/SERVICES Service Name of Practitioner Service Name of Practitioner Physiotherapist _____ Tone Management _____ Occupational Therapist _____ Other:_____ _____ Neurology _____ Other:_____ _____ COMMENTS Please attach ALL INVESTIGATIONS AND IMAGING.

3 Referrals will NOT be processed without supporting documentation REASON FOR REFERRAL Diagnosis: _____ GMFCS Level: _____ Reason for referral: _____ _____ _____ Is the child experiencing PAIN? Yes No Location:_____ Upper Extremity Involvement: Yes No OFFICE USE ONLY Date Received:_____ 4500 Oak Street, Vancouver, BC V6H 3N1 Phone: (604)875-2345 ext 3187 Fax: (604) 875-2275 Page 2 of 2


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