Patient Referral Form Guidelines

  • You represent a hospital, medical clinic or physician's office.

  • We accept retirement home placement referrals only.

  • Immediate placement requires flexibility on location.

  • Fields marked with an * are mandatory. If you do not have information for a mandatory field, entering 'none' or 'unknown' is acceptable.


Patient Referral Form

  • Hospital Details

  • Your Contact Info

  • Patient Details

  • Does the patient have a family doctor?
  • Please enter the name of the family member, friend or guardian who is responsible for this patient.
  • When does this patient require placement?
  • Does the patient have a Will or Power of Attorney
  • Is the patient working with Community Care Access Centre?
  • What is the maximum monthly budget this patient can afford?
  • Where does the patient currently reside?
  • What type of residence does this patient require?
  • Does the patient have any dietary concerns?
  • Please list any assistance requirements. Examples: Requires assistance with bathing, dressing or eating.
  • Please list any cognition concerns/diagnosis this patient has.
  • Please list any mobility limitations this patient has.
  • Is this patient considered a 'flight risk' ?
  • Will the patient have any pets living with them?
  • Will the patient require parking?
  • Please provide us any other relevant information that was not already captured on this form.
  • This field is for validation purposes and should be left unchanged.