Medical Services Referrals

Download the above referral form, and fax to 604 566 9102

 
 

Medical Services Acceptance Criteria

  • Patient has non-cancer pain that has not resolved on its own or with conventional therapies.
  • Patient is agreeable to the referral and willing to participate in the Core Program. 
  • Patient lives within our catchment area. Please note that list is subject to change. See below:
    • Vancouver
    • Burnaby
    • Richmond
    • North Vancouver
    • West Vancouver
    • Surrey
    • New west
    • Coquitlam
    • Port Coquitlam
    • Port Moody
    • Delta

Medical Services Rejection Criteria

  • Patients without Primary Care Physician or Walk-In Clinic able to provide ongoing care.
  • Patients who are not fluent in English or not able to bring a translator to every appointment.
  • Active WorkSafe BC patients, unless Worksafe BC has confirmed whether or not they will cover CHANGEpain services.

How to Refer:

 Please fax a referral with the following information:

  • Patient demographic information (name, PHN, DOB, address, phone, and email)
  • Brief description of the pain problem
  • Relevant patient medical history summary
  • Copies of relevant specialist consultation reports, imaging, labs, and medication information

Complete a no-charge referral 3333 to MSP to Dr. Brenda Lau (#26194)

Note: Dr. Lau receives all referrals on behalf of CHANGEpain. Once we receive the referral we will send the referrer an acknowledgement by fax. We will forward the referral to the CHANGEpain consulting physician as appropriate. The consulting physician will send the referrer a detailed consultation letter after completion of the first consultation and on discharge. 

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