ONLINE REFERRAL FORM

REFERRAL PROCESS FOR PHYSICIANS:

Please ensure the following are completed BEFORE faxing referral (incomplete referrals will be returned without review):

All four sections of referral form are completed. If referring MD is unable to complete all sections, consider contacting LHIN Care Coordinator to provide details
Attach most recent consult/clinic notes, first note for life limiting illness, relevant imaging reports and recent hospital discharge summary. It is the referring source’s responsibility to provide this information to ensure timely consideration
Family Physician must be notified regarding referral and agree to referral to CPMA

Please ensure your direct fax number is provided so we can notify you regarding acceptance of this referral.

If request is URGENT, contact our Administrative Assistant at 613-801-0035, ext. 200

Fax complete referral to 613-801-0036

IMPORTANT INFORMATION FOR REFERRALS OF HOSPITAL INPATIENTS:

* Consider phone contact between attending physician or palliative care physician and CPMA early in the discharge planning process.

* Inpatient palliative care consultation is strongly recommended.

* Prior to discharge, ensure that patient has adequate supplies in place at home:
        - injectable medications (fax Rx to Medical Pharmacies (Fax 613-244-4695) - do not fax to patient's retail pharmacy as they often do not stock medications we commonly use
        - supplies for subcutaneous drug administration, urinary catheter, wounds, etc. (requests can be made to LHIN for home delivery)
      - equipment that patient requires such as hospital bed, commode, wheelchair

* Complex patients should have a nursing visit at home on the day of discharge.

* Request that CCAC transfers patient to the Palliative Care Team upon discharge.

* The discharge summary, including medication list, should be faxed to CPMA at or before discharge.

* Give adequate notice to CPMA physician of projected discharge date and confirm discharge by phone on date of discharge.

CARE IS NOT ASSUMED BY CPMA UNTIL THE PATIENT IS SEEN IN HOME AT THE INITIAL VISIT

Referral Form