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 ClinicianPsychologistBC Children’s Hospital ED ProgramOther: ________________________Working ED Diagnosis:Anorexia Nervosa, Restricting typeAnorexia Nervosa,Binge-eating/Purging typeBulimia Nervosa, Purging typeBulimia Nervosa, Non-purging typeEating Disorder Not Otherwise SpecifiedLab 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 - 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 (ie, 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 she/he will not be put on our wait list until the referral process has beencompleted. This process includes your completed referral form, blood work, and ECG. Patients areencouraged to attend our Information Session, held the third Thursday of every month @ 4:30 pm at theNorth Delta Mental Health Centre. Once on the list, we will invite the patient in for a Screening and BriefOrientation Session and if appropriate an Assessment Appointment will then be scheduled.__________________________________Doctor’s Signature______________________________DateIf you have any questions re completing the referral, please call us at 604 951.5844 08/31/104