Referral Form: Fraser Health Complex Wound Healing Clinic
Jim Pattison Outpatient Care and Surgery Centre
Address: 9750 140th Street, Surrey, B.C. V3T 0G9 Phone: 604-582-4550 (JPOCSC Primary Care)
Please complete this referral form and fax it to (*Information required):
Fax: 604-953-4921 (Gateway Home Health Clinic); or 604-582-3781 (JPOCSC Primary Care Reception)
Parking and Transport Information:
A bus stop is located at the front; please visit http://www.translink.bc.ca or call (604) 953-3333.
Pay parking requires exact payment.
*Date:
*Sex:
*Name:
*Age:
Date of Birth:
*PHN:
*Address:
*Home Phone #:
Mobile Phone #:
*Wound Location:
*Wound Start Day:
*Reason/Goal for Referral:
*Is patient receiving Wound Care from Home Care Nursing (HCN)? Yes
 If Yes, HCN Start Day:
No
Pixalere # (if known):
*Known Allergy:
*Wound Etiology (please  one):
Pressure Ulcer
Trauma
Diabetic/Neuropathic Foot Ulcer
Post-Surgical
Burn/Scald
Lower Leg Ulcer (venous/arterial/Mixed)
Infectious
Inflammatory
Unknown
Other
*Comorbidities/Wound Healing Impeding Factors (please  all that applies):
Pressure
Diabetes/Neuropathy
Nutrition
Obesity
>20mg/day)
Venous Stasis
Tobacco Use
Infection
Inflammation
Peripheral Edema
Immobility
Immunosuppression
Foreign Body
Granuloma
Arterial Insufficiency
Prednisone/Steroid Use
Patient Adherence
Other
*Current Dressing Protocol:
Dressing Products Previously Used:
*Is patient able to transfer independently? Yes
No
(***Patient must be able to transfer
independently or with the assistance of accompanied family/caregiver)
Language spoken:
Interpreter required? Yes
No
Please attach any pertinent recent lab work, pathology reports, medical imaging reports, etc.
*Referee Name:
*Program/Unit:
Fax Number:
Complex Wound Clinic Referral Form – Final – April 7, 2015
Title:
*Phone Number:
e-mail address:
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Fraser Health Complex Wound Clinic Patient Referral Criteria (no need to be faxed)
Mission
With a person-centered and interprofessional team approach, promote wound healing of persons with
difficult-to-heal non-malignant wounds that have adequate perfusion
Vision
Promotes healable wounds healing by:
1. Providing optimal wound care, including sharp wound debridement, infection/inflammation
control, and moisture balance
2. Addressing the person-center concerns with consideration to the physio-psycho-socio-economic
impact of chronic wounds on the patients including pain, treatment cost, social activities, family
relationships, worklife, etc.
3. Providing person-centered education to promote healthy life-style change, and ability to selfmanagement
4. Developing a mutually agreed upon cost-effective treatment plans to enable self-management
or for Home Care Nursing to provide optimal wound care to patients unable to self-manage
Inclusion Criteria1:
 Patients of age 19 and over
 Patient of age under 19 in collaboration with Child and Youth Services
 Patients with lower leg/foot ulcers with ABI >0.5 (if ABI<0.5, refer to vascular surgeon first)
 Even with standard wound care2 (Sheehan 2013, Coerper et al 2009):
 Patients with acute wounds that fail to heal in 6 week
 Patients with chronic wounds that fail to heal in 12 weeks3
 Patients with chronic wounds that fail to have 30% size reduction (length x width) after 4
weeks of standard wound care
 Patient can transfer independently or assisted by accompanied caregiver
 Patient is committed to:
 Adherence to clinic visits
 Adherence to treatment plan
 Tobacco reduction/cessation
 Optimal nutrition, including protein, calorie, fluid
 Optimal Diabetic control with A1C < 9
Exclusion Criteria:
 Patients’ wounds have not been managed with standard wound care4
 Home bound patients who cannot attend the clinic visit
 Patients who require mechanical lift for transfer
 Patients with lower leg/foot ulcers with ABI <0.5, and are not a candidate for revascularization
 Patients cannot commit to the wound treatment plan, clinic visits, healthy life style modifications,
tobacco reduction/cessation, optimal nutrition intake, Diabetic control, etc.
1 1Exception
may be considered for individual client/patient in collaboration with Home Health WCCs and/or Medical
Professionals managing complex acute or chronic wounds (e.g. ID Specialists, Surgeons). Please contact the Complex
Wound Clinic CNS directly via e-mail (marine.chan@fraserhealth.ca) or by phone (604-218-9763).
2
Fraser Health Home Care Nursing (HCN) provides standard wound care
3
Refer patients to Complex Wound Clinic if patients’ wounds not responding to standard wound care provided by HCN
4
Non-HCN patients, please refer patient to HCN for standard wound care (Home Health Service Line 1-855-412-2121)
Complex Wound Clinic Referral Form – Final – April 7, 2015
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