Geriatric Ambulatory Clinic

REFERRAL FORM

Please check one of the boxes below to indicate which Elder Care Ambulatory Clinic your patient can go to:

St. Paul’s HospitalMount Saint Joseph Hospital

9B-1081 Burrard Street3080 Prince Edward Street

Vancouver, BC V6Z 1Y6Vancouver, BC V5T 3N4

Phone: 604-806-9827Phone: 604-877-8371

Fax: 604-806-8390Fax: 604-877-8149

Referral Date: / Referral Source:Contact #:
Patient’s Name: / DOB: (mm/dd/yy) / Male
Female
Patient’s Home Address: / Phone No:
PHN:
PARIS #: (if available)
Language(s):
Interpreter needed / Living Situation:
Alone Other:
Facility:
Key Family Contact: (call this person for appointments) Yes No
Name: Phone(s):
Relationship:
Family Physician:
Name:
Office Phone No: / Date last seen:
Fax No:
Other Physicians/Agencies Involved:

Reasons for Referral:(please review the back for further information):

Geriatric Assessment Geriatric Psychiatry Physiotherapy Clinic

Falls Clinic Advanced Care Planning Memory Clinic

Sleep HygieneManagementContinence ManagementHome Visits (Geriatrician at MSJ)

Other:

Pleasecomplete page 1 of this ReferralForm and:
FaxtoSt. Paul’s Hospital (604-806-8390) ORMount Saint Joseph Hospital (604-877-8149)
  • Attach copies of all relevant information, including current medications, allergies, diagnostic and other consult reports

Telephone referrals are also accepted.

Geriatric Ambulatory Clinic

REFERRAL FORM

The Geriatric Ambulatory Clinics at St. Paul’s Hospital and MountSaint JosephHospital provide an interdisciplinary approach in addressing the health care needs of adults over 65 years of age and their caregivers. We are committed to:

  • interdisciplinary assessment and management
  • strong liaison with community and hospital services
  • ensuring accessibility and continuity of care

We accept referrals via telephone or fax:

St. Paul’s HospitalMount Saint Joseph Hospital

Elder Care Ambulatory ClinicElder Care Ambulatory Clinic

Phone: 604-806-9827Phone:604-877-8371

Fax: 604-806-8390Fax: 604-877-8149

We have the following resources:

  • Geriatric Medicine and Geriatric Psychiatry
  • Physiotherapy and Balance Training
  • Psycho-Social Care and Family Support
  • Advanced Care Planning
  • Occupational Therapy and Falls Assessment
  • Neuropsychological Assessment
  • Nutritional Assessment and Support
  • Functional Memory Training (Individual/Group)

Reason for Referral

Geriatric Assessment Patients over age 65 with complex chronic medical (multi-system failure), functional and psychiatric issues

  • Geriatric Psychiatry
    Patients with a psychiatric diagnosis or behavioral features of dementia
  • Physiotherapy Clinic

Falls ClinicPatients over age 65 with history of falls or gait/balance deficit (no significant cognitive impairment)

  • Advanced Care Planning
  • Continence Clinic
  • Memory Clinic
    For assessment/management of dementia, MCI and related disorders (emphasis on early intervention)
  • Sleep Hygiene Clinic (offered by the Occupational Health Therapist)
  • Home Visits by the Geriatrician at MSJ
    (for Home Visits, please contact the local Community Health Centre)
  • Geriatric Psychiatry Outreach

Form No. PHC-EL074 (R. Jun-11)Page 1 of 2