Current Page 1 Page 2 Preview Personal health information on this form is collected by Health PEI for the purposes of patient care and for other purposes permitted by the Health Information Act, including the planning and management of health services. Patient information will be collected, used and disclosed only as permitted by law. For more information, visit www.healthpei.ca/yourprivacy or contact the PEI Cancer Treatment Centre at 902-894-2027. Referrer Identification Who is filling out this form? If you are completing this form on behalf of the referring provider, select “other” to add your name/role to the “other” field. Then proceed by entering the referring provider’s name and contact details. - Select -Nurse PractitionerPrimary Care PhysicianSpecialist ProviderER PhysicianPhysician AssistantHospitalistSurgeonOther Other: First Name of Referring Provider Last Name of Referring Provider Telephone Number For example 902-555-5555 Fax Number For example 902-555-5555 What statement best describes the situation? - Select -I am a PEI physician/nurse practitioner referring a patient within PEI.I am a Canadian physician/nurse practitioner referring a patient from outside PEI.I am a physician/nurse practitioner referring a patient from outside Canada. What statement best describes the situation? - Select -A PEI physician/nurse practitioner is referring a patient within PEI.A Canadian physician/nurse practitioner is referring a patient from outside PEI.A physician/nurse practitioner is referring a patient from outside Canada. Is the patient a resident of PEI with a valid PEI Health Card? - Select -YesNo Is the patient a Canadian resident? - Select -YesNo Country of residence: Please indicate the patient’s home province: - Select -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioQuebecSaskatchewanNorthwest TerritoriesNunavutYukon Health Card Number Health Card Number Is the patient currently admitted to hospital? - Select -YesNo Where is the patient admitted? - Select -Queen Elizabeth HospitalPrince County HospitalOther Hospital Name: Hospital Name: Hospital Name: Hospital Name: Hospital Location: Hospital Location: Patient Identification First Name Last Name Date of Birth PEI Health Card Number Medical Record Number (MRN) Medical Record Number (MRN) Patient Phone Number For example 902-555-5555 Alternate Contact Name Relationship to Patient Alternate Contact Phone Number For example 902-555-5555 Is the patient fluent in English? - Select -YesNo Is the patient fluent in English? - Select -YesNo Is the patient fluent in English? - Select -YesNo What is their first language? Indicate if the patient has special needs we should be aware of at the clinic (e.g. interpreter, cultural needs, physical impairment, sight/hearing impairment, etc.): I believe this patient may benefit from the support of the Cancer Patient Navigator (e.g. cancer-related distress; known barriers to treatment; lack of supports; challenges navigating health system; etc.)