Tall Tree Health — Physician/NP Referral (OSCAR eForm) Physician / NP Referral Form — Tall Tree Health Commercial Drive (Vancouver) • James Bay (Victoria) • Cordova Bay (Victoria) • Port Coquitlam DATE Preferred Location Vancouver — Commercial Drive 956 Commercial Dr • P: (604) 258-9186 • F: (604) 336-5601 James Bay — Victoria 555 Superior St • P: (250) 995-0067 • F: (778) 698-3697 Cordova Bay — Victoria #140-5325 Cordova Bay Rd • P: (250) 658-9222 • F: (778) 440-9222 Port Coquitlam — Marpole Ave 2331 Marpole Ave • P: (604) 500-7811 • F: (778) 729-0109 Select one or more locations. Patient Information Name PHN DOB Gender Phone Address Referring Physician / NP Name MSP # Clinic Name (if applicable) Phone Fax Address Recommended Treatment / Services Physiotherapy Kinesiology Occupational Therapy Chiropractor Massage Therapy Clinical Counselling Psychology Nature Therapy ICBC Injury Worksafe Injury Dietician Speech Therapy Concussion Therapy Vestibular Therapy Pelvic Health Therapy Pain Education Purpose of Referral Assessment Graded Exercise Program Strength Training Balance Training Aerobic Training Return to Work Manual Therapy IMS or Acupuncture Orthotics and Bracing Psychosocial Focus (if applicable) Depression Anxiety / Stress PTSD / C-PTSD End of Life Grief and Loss Health Behaviour Change Coping With Illness / Injury Family / Relationships Life Transitions Other Referrer Communication Preferences No communication needed Send a progress report Send assessment findings & treatment plan Send a discharge summary Doctor Signature By signing below I support a referral for this patient to the services outlined above for management of injury-related issues. Treatment recommended is reasonable and necessary to support this client to return to normal function. Doctor Name Date
