Referrals.

Download our referral form here

Or see below for an online fillable format

REFERRAL FORM

A referral is required prior to booking your appointment with The Milk Clinic.

Referrals are accepted from:

Physician: such as your family physician, obstetrician, pediatrician or a walk-in or virtual doctor
Midwife.
Nurse: including a nurse practitioner (NP) or registered nurse (RN) such as from public health, a phone line or the hospital
Social Worker.

Appointments are covered by MSP from pregnancy to 6 weeks postpartum

Referral Form

Photo used with permission from the KCR & IH Breastfeeding Systems Change Project

Information for referring practitioners:

Please refer BOTH the parent and baby(s) when applicable.
Referrals are not accepted for families that are greater than 6 weeks postpartum.
Referrals can be made via:
- consult letter
- downloaded consult form
- website form
please fax consultation to 833-844-6455, or if from the South Okanagan use 778-646-2557

Referral form

PATIENT DEMOGRAPHICS:

Name

First Name

Last Name

Date of Birth

YYYY

PHN

City/Town/Reserve/Settlement

Phone

Country

(###)

###

####

Baby(s) Name

First Name

Last Name

Baby(s) DOB

YYYY

Baby(s) PHN

REFERRAL:

Patient is currently

If pregnant, EDD is

YYYY

Urgency

Location

Reason for referral

Anticipatory support and education

History of challenges

Current challenges

Risk factors present

Patient request

Additional information

such as birth and most recent weights, relevant feeding history, etc.

REFERRING PROVIDER INFORMATION:

Name

First Name

Last Name

Profession

Billing number (if applicable)

Today's Date

YYYY

fax number

(###)

###

####

I declare that the patient information I have provided above is accurate and complete.