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PATIENT REFERRAL FORM
Referral Re-Referral (patient previously seen at BCCA) Date of Referral
In order to process this referral/re-referral, a completed form with essential documentation should be
directed to the Cancer Centre or Clinic*
For URGENT REFERRALS please contact an Oncologist directly at your Regional Cancer Centre.
If oncologist contacted, please provide oncologist’s name
Abbotsford Centre 604-851-4710 | Centre for Southern Interior 250-712-3900 | Centre for the North 250-645-7300 |
Fraser Valley Centre 604-930-2098 | Vancouver Centre 604-877-6098 | Vancouver Island Centre 250-519-5500
For PATH REVIEW ONLY please complete Pathology Request Form..
If you require assistance, please call 604-877-6000 ext. 672071 (Monday to Friday 8:00am-4:00pm)
HAS PATIENT BEEN INFORMED OF CANCER DIAGNOSIS? Yes No
CLINICAL/PATHOLOGICAL DIAGNOSIS
Name Male Female D.O.B. / /
(Last Name) (First Name) (Initial)
PHN #
(
Day)/(Month)/(Year)
Self Pay Yes No
Address
(Street)
Home Phone
(City)
Work Phone
(Province) (Postal Code)
Contact/Message Phone
Referring Physician Phone # Billing #
Family Physician Phone # Billing #
Consultant Phone # Billing #
PROCEDURES/IMAGING RELATIVE TO CONDITION & PENDING PROCEDURES/TESTS
Operations/Procedures/Imaging
Hospital/Office
Date
SPECIAL PATIENT NEEDS/TREATMENT
Needs Accommodation: (CSI/VC/VIC only)
Needs Interpreter/Dialect
Specify: ______________________
Patient & Family Counseling Referral
Other Special Needs (include sight, hearing/physical impairments, oxygen, infection control such as MRSA, latex allergy)
Hospital Bed Required (physician must contact BCCA oncologist)
Patient Currently in Facility
Name
***ESSENTIAL REFERRAL INFORMATION: Please fax your referral letter/pathology reports/radiology reports/patient history/related
consultations and procedure reports to the appropriate Cancer Centre (fax numbers below).
Please send additional documents as per the essential information list referred to at the BCCA website
www.bccancer.bc.ca/HPI/CancerManagementGuidelines/ReferralInformation/default.htm
Forms are available at the BCCA website http://www.bccancer.bc.ca/Documents/Patient-Referral-Form.pdf
Please choose Centre or Clinic:
Abbotsford Centre Phone: 604-851-4732 or 604-851-4737 Fax: 604-675-7204
Centre for the Southern Interior (Kelowna) Phone: 250-712-3969 or 250-712-3970 or 250-979-6622 Fax: 250-979-4001
Centre for the North (Prince George) Phone: 250-645-7318 or 250-645-7319 Fax: 250-645-7371
Fraser Valley Centre Phone: 604-930-4004 or 604-930-4016 or 604-587-4301 Fax: 604-675-7222
Kamloops Clinic Phone: 250-314-2734 Fax: 250-314-2733
Nanaimo Clinic Phone: 250-716-7706 Fax: 250-755-7676
Vancouver Centre Phone: 604-877-6098 Fax: 604-708-2005
Vancouver Island Centre Phone: 250-519-5585 or 519-5586 or 519-5587 Fax: 250-519-2001
Vernon Clinic Phone: 250-558-1235 Fax: 250-558-4113
Confidential Fax Warning: Documents accompanying this transmission contain confidential information intended for a specific individual
and purpose. This information is private and protected by law. If you are not the intended recipient and have received this communication,
please notify sender by phone. Number of pages faxed _________
revised 14 July 2015