Created by Dr. Ian Bekker. Referral form for the Outpatient Pain Management Clinics run by Vancouver Island Health Authority. I have made some modifications: radio X-boxes, increase or decrease font size in textarea, added placeholders, added links to other parts of the chart, added link to second page (so that you have the option to print or not print it), added email link (look at the bottom of the page), added web link - top left of the page.
V3_Mar5_2022 updated with new background. It's a 2 pager, but the 2nd page is reference only. Web links updated. Click to copy fax and phone included. Sorry - there is no fax control in this version.
V4_Mar25_2022 has the correct PHONE and FAX numbers for NRGH. Sorry - there is no fax control in this version.
The NRGH phone # is 250-739-5978, and Fax # is 604-739-5989.
|VIHA_Outpatient_Pain_Management_Referral_2020_V2_NoFC.zip no faxControl||Download |
|VIHA_Outpatient_Pain_Management_Referral_2020_V2.zip with faxControl.js||Download |