Caredove

Request to Become a Referrer

Name:*

Email:*

Organization:*

Job Title:*

Work Phone:*

Message*

Cancel

Service Information
Form
Finish

Service Information

Service:

PCO - Primary Care Outreach to Seniors
Organization: South-East Ottawa Community Health Centre
Description:

Offers free in-home services provided by Registered Nurses and Community Health Workers. Our goal is to help connect isolated and/or vulnerable seniors living at home with the care and resources they require to live safely and foster their wellbeing.

Provided at client’s home and various community locations.

Referral Options:

Please check the following criteria that apply to the client:*

Does not have family doctor

Lives alone/isolated and has no support network (friends, family)

Difficulty keeping appointments/No-shows

Fear or concerns re: abuse

At risk of eviction / low Income

Recent loss within 1 year

ED visit in last 3 months

Taking > 3 medications

Fallen in last 3 months

New medical diagnosis < 3 month

Chronic illness/pain monitoring

Unexplained weight loss

Recent change in mood/behaviour

Recent change in cognition/memory

Other

Required: choose at least one option

If other, please specify:

Does the client currently receive any of the following services?*

Home and Community Care Support Services

Home Support

G.P.C.S.O

Geriatric Day Hospital

G.A.O.T

Other

None

Required: choose at least one option

Please specify:

Eligibility:*

Are these eligibility requirements met?

Client is an older adult who is isolated / vulnerable / suffers from chronic illness or pain / has memory challenges / has concerns for general safety / social determinants of health.

Yes

No/Unsure

Warning: Submission may be denied, please provide more details.

This field is required

Minimum Age: 65 yrs

Yes

No/Unsure

Warning: Submission may be denied, please provide more details.

This field is required

Client Information

Client Name:

First name*

This field is required

Family/Last Name*

This field is required

Personal Pronouns:

This field is required

Email Address:

Email (Confirmation and reminder emails will be sent here)

This field is required

Phone:

Primary Phone*

This field is required

Secondary Phone

This field is required

Address:

Unit/Suite #

This field is required

Street # & Street Name*

This field is required

City*

This field is required

Province/State

This field is required

Postal/Zip Code

This field is required

Select location on a map

Gender:

Male

Female

Other

This field is required

Date of Birth:

Day

Month

Year

Age: ( corrected)

This field is required

Ineligible - You have specified age of .

The age eligibility requirements for this service is:

Warning: Submission may be denied.

Client Health Card Number:

Client Health Card Number

This field is required

Version Code

This field is required

Language:

What is the preferred Language?

This field is required

Is an interpreter required?

Yes

This field is required

Conduct Appointment With:

Client

Alternate Contact

This field is required

Alternate Contact

Relationship to Client:

Spouse

Son/Daughter

Sibling

Parent

Other

This field is required

Alternate Contact Name:

First name

This field is required

Family/Last Name

This field is required

Alternate Contact Email Address:

This field is required

Alternate Contact Info:

Same contact information as Client

Primary Phone

This field is required

Secondary Phone

This field is required

Health Information

Reason for Referral:

e.g., New Diagnosis, Recent hospital admission, Caregiver burnout, etc..*

This field is required

Additional Information

Does the client have a Primary Health Care Provider (e.g., MD or NP)?:*

This field is required

Primary Healthcare Provider's name, phone # and fax #:

Is the Primary Healthcare Provider aware of this referral?:

Please describe other services client currently has access to:*

This field is required

Expectations from PCO or goals of referral source:*

This field is required

Does the client have any infectious diseases? (i.e., HIV, HEP C, C DIFF, MRSA, TB, VRE):*

This field is required

Medical condition:*

This field is required

Does the client have a health card?:*

Yes / No:

This field is required

Referral source:*

This field is required

Documentation:

Attach additional documentation as needed (e.g. Discharge Summary)

Add files

Are you sending any additional documentation separately by a method other than online through Caredove (e.g, via fax)?

Yes

Consent

The client is aware of this referral and has granted consent to send this referral to PCO.

Yes

This must be to continue

This field is required

clear consent values

By clicking "Finish", you agree to send this personal information to South-East Ottawa Community Health Centre online.

You agree to these Terms and Conditions and Privacy Policy, which govern how your personal information is kept safe.

Notifications:

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

Yes

To receive notifications, please select Yes.

Submission complete

The information has been submitted to South-East Ottawa Community Health Centre, but you have some steps left:

Save Confirmation
Print a handout to give to the registrant.

A confirmation message will be sent to - -

Summary

Reference #: -

Registrant:
Organization:

South-East Ottawa Community Health Centre

Service:

PCO - Primary Care Outreach to Seniors

Inquiry Phone:

1 (844) 726-5115

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

Cancel

Appointment Service area map

Red area: Service area for this appointment

Grey area: Service delivery area

Home Address

Trip Map

Driving Distance: 0km

Select Form Name

Name:*

This field is required

Add Form Name

Name:*

This field is required

Select Location on a Map

You need Javascript enabled to use Caredove. Please visit diagnostics page for more information. #noscript-warning { font-family: sans-serif; position: fixed; top: 0; left: 0; width: 100%; z-index: 101; text-align: center; font-weight: bold; font-size: 120%; color: #FFF; background-color: #AE0000; padding: 5px 0 5px 0; }