Emergency Department Fax Referral
Chilliwack General Hospital
Fax: 604-701-4061
Date: Y-M-D
Referring MD/NP:
Name:
MSP #:
Phone:
Fax:
Patient Info:
Name: (Last, First)
Age:, DOB:
PHN:
Reason for Referral:
Patient’s Relevent History and Physical:

        Please attach a copy of relevant clinical records if available.

To be completed by ER Physician:

Your patient was assessed by: ______________________________________, MSP #: __________________

Patient Disposition: ________________________________________________________
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Subject:
Creative Commons License created February 5th 2021 by Dr. John Robertson, licensed under a GPL.
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