Caredove

Service Information

Service:

Lung Health Program
Organization: Seaway Valley Community Health Centre
Description:

Have your COPD/asthma care managed by a Nurse Practitioner and Respiratory Therapist. Learn more about lung disease, medications & how to prevent attacks.

Referral Options:

Please check all that apply to you:*

I have been diagnosed with a breathing problem

I take medications to help with breathing

I have had a breathing test

I smoke

I cough regularly

I cough up phlegm regularly

I wheeze at night or when I exert myself

I get frequent colds that last longer than other people’s

Required: choose at least one option

Client Information

Client Name:

First name*

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Family/Last Name*

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Email Address:

Email (Confirmation and reminder emails will be sent here)

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Phone:

Primary Phone*

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Secondary Phone

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Address:

Unit/Suite #

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Street # & Street Name*

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City*

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Province/State

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Postal/Zip Code

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Date of Birth:

Day

Month

Year

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Ineligible - You have specified age of .

The age eligibility requirements for this service is:

Warning: Submission may be denied.

Health Information

Medications:

List all medication, and dosages per day

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Relevant Medical History:

If you have been diagnosed with a breathing problem, what was the diagnosis?

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Additional Information

Messages:

Notifications:

Send confirmation, change & reminder messages to < name > < email >

Yes

Submission complete

The information has been submitted to Seaway Valley Community Health Centre, but you have some steps left:

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Summary

Reference #: -

Registrant:
Organization:

Seaway Valley Community Health Centre

Service:

Lung Health Program

Inquiry Phone:

1 (613) 936-0306

Tip: Referrals can be viewed by navigating to referrals in the top menu

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