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 Hospital
Mount Saint Joseph Hospital
9B - 1081 Burrard Street
Vancouver, BC V6Z 1Y6
Phone:
604-806-9827
Fax:
604-806-8390
3080 Prince Edward Street
Vancouver, BC V5T 3N4
Phone:
604-877-8371
Fax:
604-877-8149
Referral Date:
Referral Source:
Contact #:
Patient’s Name:
DOB: (mm/dd/yy)
Patient’s Home Address:
Male
Female
Phone No:
PHN:
PARIS #: (if available)
Language(s):
Living Situation:
Alone
Interpreter needed
Other:
Facility:
Key Family Contact: (call this person for appointments)
Name:
Yes
No
Phone(s):
Relationship:
Family Physician:
Date last seen:
Name:
Fax No:
Office Phone No:
Other Physicians/Agencies Involved:
Reasons for Referral: (please review the back for further information):
Geriatric Assessment
Falls Clinic
Sleep Hygiene Management
Other:
Geriatric Psychiatry
Advanced Care Planning
Continence Management
Physiotherapy Clinic
Memory Clinic
Home Visits (Geriatrician at MSJ)
Please complete page 1 of this Referral Form and:

Fax to St. Paul’s Hospital (604-806-8390) OR Mount 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.
Form No. PHC-EL074 (R. Jun-11)
Page 1 of 2
Geriatric Ambulatory Clinic
REFERRAL FORM
The Geriatric Ambulatory Clinics at St. Paul’s Hospital and Mount Saint Joseph Hospital 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 Hospital
Elder Care Ambulatory Clinic
Mount Saint Joseph Hospital
Elder Care Ambulatory Clinic
Phone:
Fax:
Phone:
Fax:
604-806-9827
604-806-8390
604-877-8371
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 Clinic
Patients 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 2 of 2