VGH ORAL HEALTH CENTRE Gordon & Leslie Diamond Health Care Centre 7th Floor - 2775 Laurel Street Vancouver, BC V5Z 1M9 Telephone: 604-875-4006 Fax Requisition: 604-875-5493 V G H O R A L H E A L T H □ HOSPITAL DENTISTRY REFERRAL TO: C E N T R E R E F E R R A L F O R M □ ORAL MUCOSAL DISEASE PROGRAM □ OROFACIAL PAIN PROGRAM N o t e : The VGH Oral Health Centre mandate is to treat patients with serious medical problems that increase the risk of the dental procedure. P L E A S E BILLABLE TO: □ MSP P R I N T □ ALLERGIES (PLEASE LIST): C L E A R L Y □ ICBC □ WCB PERSONAL HEALTH NUMBER: □ PATIENT NAME / ADDRESS OF REFERRING PHYSICIAN or DENTIST AND MSP PRACTITIONER # (or office stamp) □ OTHER DOB: YYYY/MM/DD | SURNAME OF PATIENT, TELEPHONE# (INCLUDE AREA CODE): ADDRESS | FIRST NAME AND MIDDLE INITIAL □ MALE □ FEMALE CITY/TOWN POSTAL CODE COPY RESULTS TO: □ TRANSLATION SERVICES REQUIRED: (INDICATE LANGUAGE) _____________________________________________________________________ P E R T I N E N T H I S T O R Y REASON FOR REFERRAL (CHECK ALL THOSE THAT APPLY): □ CENTRAL NERVOUS SYSTEM DISORDERS □ CARDIOVASCULAR DISORDERS □ RESPIRATORY DISORDERS □ RENAL DISORDERS □ HEMATOLOGIC DISORDERS □ HEPATIC DISORDERS □ ENDOCRINE DISORDERS □ NEOPLASTIC DISORDERS □ INFECTIOUS OR IMMUNE DEFFICIENCY □ METABOLIC DISORDERS □ OTHER DISORDERS OR CONDITIONS: PLEASE LIST IN HISTORY BRIEF HISTORY AND FINDINGS: ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ CURRENT MEDICATIONS: ________________________________________________________________________________________________________________________________ CONTACT PERSON FOR APPOINTMENT IF NOT THE PATIENT SURNAME, FIRST NAME TELEPHONE# (INCLUDE AREA CODE): PLEASE ATTACH ALL RECENT BLOOD/LABORATORY/IMAGING & OTHER PERTINENT RESULTS P L E A S E N O T E ALL REFERRAL INFORMATION MUST BE COMPLETED IN FULL. INCOMPLETE REFERRALS WILL BE RETURNED. PLEASE ADVISE PATIENTS THAT ALL REFERRALS REQUIRE AN INITIAL CONSULTATION. TREATMENT MAY NOT BE PROVIDED AT THE FIRTST VISIT. A FEE WILL BE CHARGED TO PATIENTS WHO FAIL TO PROVIDE 48 BUSINESS HOURS NOTICE OF CANCELLATION FOR A SCHEDULED APPOINTMENT ACKNOWLEDGEMENT OF REFERRAL: □ YOUR PATIENT’S VGH ORAL HEALTH CENTRE CONSULTATION IS SCHEDULED ON ___________________________________________ O U R F A C I L I T Y I S A F R A G R A N C E F R E E Z O N E