Chronic Disease Management
Wellness Centre Campbell River Hospital
375- 2
nd
Ave
Campbell River, B. C. V9W 3V2
Phone: 250-286-7151 Fax: 250-286-7103
UVB Phototherapy Program
May 2018
Referral / Order Form
FAX to: 250-286-7103
Last Name:
First Name:
Date of Birth: (dd/mm/yy)
PHN:
Address:
Home Phone:
Cell Phone:
Alternate Contact:
Relationship to Client:
Alternate Phone:
Diagnosis: (include recent documentation from
Dermatologist)
Areas for UVB Narrow Band Phototherapy
Treatment:
Medications: (concern for photosensitivity)
Number of weekly treatments or Maintenance:
History:
Concerns:
Date of Referral:
Physician/NP Signature:
Physician/NP Stamp or Print
Name and Clinic:
Referral renewal is required every six months to prevent interruption of client treatments.
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