Process - Physician - Fraser Health Authority

Current Treatment for ED /Psychiatric concerns? Yes NoPast Treatment for ED /Psychiatric concerns? Yes NoIf “yes”, please indicate who else is/was providing services for this clientPsychiatristMental Health ClinicianPsychologistSt. Paul’s Hospital ED programBC Children’s Hospital ED Program Other: ________________________Lab Work – A current (within 2 months) copy of the following is required:1) ECG2) Full blood biochemistry including all of the below:- CBC and Diff - Serum Phosphate, Magnesium, Zinc- Ferritin, B12 - BUN, Creatinine- Random Blood Sugar - Na, Cl, K, Bicarb- TSH - Serum Protein- ALT, AST, Alk Phos, Bilirubin3) Microscopic Urinalysis to include Specific Gravity.PLEASE REMEMBER TO INCLUDE: (1) all relevant tests (i.e. blood work and ECG),(2) symptoms and frequency,(3) current height and weight,(4) highest and lowest weights, and(5) GP contact info as you will be providing on-goingmedical care for this patient.Please advise your patient that we have a waiting list of at least several months and that she/he will not be put on ourwaiting list until the referral process has been completed. This process includes your completed referral form, blood work,and an ECG. Once on the list, we will invite the patient for an Orientation Session.__________________________________Doctor’s Name & Signature______________________________DateIf you have any questions re completing the referral, please call us at 604-777-8400 and ask for Intake.05/05/094