Referral form for professionals
Strictly confidential.
Refer patients, clients, students, staff, or community members
This Referral Form is intended for intake and care coordination purposes from referring health care professionals, legal representatives, and organizations seeking support for their clients or patients. It does not constitute medical advice, diagnosis, or treatment. The information you provide will be kept strictly confidential and accessed only by authorized staff for the purposes to which you have consented. To protect patient/client confidentiality, please complete this form in a private setting.
Questions?
If you have questions about referring a patient or client, please contact Registered Nurse Sheila Baxter directly. The referral form provides options for you to indicate the levels of care conferencing and team-based care that align with your practice, with consent from the person receiving treatment.
Text us: (250) 818-1218
Email us: nanaimo@laserhealthcenters.ca
Our clinic will make every effort to accommodate your availability. A member of our care coordination team will contact you in advance to confirm scheduling details.
All communication will be conducted in accordance with applicable privacy legislation, and is contingent upon a signed release of information from the referred individual. If your preferred method cannot be accommodated securely, our clinic will contact you to arrange an appropriate alternative.