Thames Valley Childrens Centre 779 Base Line Rd. E., London ON N6C 5Y6 Intake: 519-685-8716 Fax: 519-685-8705 www.tvcc.on.ca For questions, e-mail: intake@tvcc.on.ca

PHYSICIAN REFERRAL FORM

Todays Date: File No. (Office Only)

Client Information: Clients Name: DOB: Gender: Health Card Number: Version Code: Expiry: Primary Diagnosis: Given by:

Parent/Legal Guardian Contact Information: Relationship:

Address: Primary Contact:

City: Postal: Primary Phone Number: Language Spoken: Interpreter Required: Yes No

Referral reason and requested service(s):*

* See below and reverse side for a description of services

REFERRAL SOURCE Physician Referring Number:

Address: Referred by:

Referring Signature: City: Phone: Postal Code: Fax:

Physician referral is required for the services below. May include PT, OT, SLP, SW and RN Service Name Description Amputee Clinic Consult: Orthopaedics

Cerebral Palsy Clinic For individuals with complex tone, seizures or feeding/swallowing issues Consults: Neurology, Paediatrics, Gastroenterology and Physiatry

Cleft Lip/Palate (CLP) and Oral Facial Anomalies Clinic

Consults: Plastic Surgery, ENT, Paediatric Dentistry Dentist/Orthodontic contact information is required

Dental Funding Clinic Assessment of eligibility for funding for dental services for CLP, craniofacial anomalies, congenital oral defects and acquired facial/oral defects. Dentist/ physician referral and Dentist/Orthodontic contact information is required

Modified Barium Swallow Assessment

Conducted at Children's Hospital with a Radiologist to assess for aspiration. Fax referral to LHSC 519-685-8695, X ray requisition must accompany referral

Neuromuscular Clinic Consults: Neurology, Orthopaedics, Respirology, Dev. Paed, and/or Genetics Paediatric Acquired Brain Injury Community Outreach Program

Medical, educational and social support to children/youth who sustain brain injury after the age of 7 days in Middlesex, Oxford, Elgin, Huron and Perth

Orthopaedic Clinic Please check: General Orthopaedic Gait Lab Paediatric Assessment Clinic Consult: Developmental Paediatrician. Paediatrician referral required

Thames Valley Children's Centre, 779 Base Line Rd E, London ON N6C 5Y6 Phone: 519-685-8700 or 1-866-590-8822 Fax: 519-685-8705 P a g e | 1

mailto:intake@tvcc.on.cahttp:www.tvcc.on.ca

Thames Valley Children's Centre, 779 Base Line Rd E, London ON N6C 5Y6 Phone: 519-685-8700 or 1-866-590-8822 Fax: 519-685-8705 P a g e | 2

Rett Syndrome Clinic Consults: Genetics, Neurology, Gastroenterology, Paediatrics and Physiatry

Spina Bifida Clinic Consults: Neurosurgery, Paediatrics, Orthopaedics, Urology and Physiatry

Upper Extremity Clinic Consult: Plastic Surgery

Velopharyngeal Dysfunction Assessment and Treatment

SLP assesses speech and resonance with further consultation from ENT and Prosthodontics as appropriate

Services below can be requested by families or community professionals: Service Name Description Augmentative Communication Service (ACS)

Support for developing alternative ways to communicate in person or in writing when speech or handwriting is not functional

Autism Services Offers behavioural services to children/youth with ASD up to and including 18 yrs of age that are flexible, individualized and based on their needs Please note: A written diagnosis of ASD is required from a qualified professional

Bowel & Bladder Management Assessment and education of catheterization bowel/bladder management Brachial Plexus Treatment Acute therapy following obstetrical nerve injury to the upper extremity Occupational Therapy (OT) Assessment, intervention and consultation for kids from birth to school entry

Parent Mentor Service Work with families to develop/maintain effective relationships with child/ youths school by enhancing understanding, planning and problem solving Physiotherapy (PT) Assessment, intervention and consultation from birth to school entry School Health Support Services (OT, PT or SLP)*

*Contact the childs school principal or resource teacher to request OT, PT or SLP

Seating and Mobility Services Assessment, prescription and fitting of clients in need of seating supports and mobility bases (strollers, wheelchairs, scooters)

Speech/Language Therapy (SLP) For preschool referrals: Grey/Bruce county - complete this referral form Middlesex, Elgin, Oxford counties - contact TykeTALK 519-663-5317 ext 2224

Splinting & Casting Fabrication of hand splints, ankle night splints and serial casting. Consultation with community OTs available for hand splinting.

Therapeutic Recreation Offer opportunities and support for children and youth to develop and maintain skills, knowledge and behaviours in recreation and leisure areas Torticollis Treatment Acute therapy for infants presenting with decreased neck range of motion

Youth Discovery Service Assist teens (12 years +) to plan their future, explore interests, hopes and dreams. Complements planning process at school and with other agencies.

Youth for Youth Service Assist youth ages 12-21 develop life skills, create meaningful connections with other youth, develop independence and gain new experiences

PHYSICIAN REFERRAL FORMClient Information:Parent/Legal Guardian Contact Information:Referral reason and requested service(s):*REFERRAL SOURCEPhysician referral is required for the services below. May include PT, OT, SLP, SW and RNServices below can be requested by families or community professionals:TVCC Referral Form Doctor Page 2017 Page 2.pdfServices below can be requested by families or community professionals:

Client's Helath Card Version Code: Client's Primary Diagnosis: Diagnosis Given By: Primary Contact Relationship: Primary Contact Address: Client's Name: Client's Health Card Expiry: Primary Contact's City: Primary Contact's Postal Code: Client's Health Card Number: Client's Health Phone Number: Language Spoken: Gender: Yes Interpreter Needed: OffNo Interpreter Needed: OffReferral reason and requested services: Primary Contact Name: Referral Source Address: Referral Source Phone Number: Referral Source Fax: Referral Source Name: Physician Referring Number: Physician Referring Signature: Referral Source City: Referral Source Postal Code: Client's Date of Birth: Today's Date: File No: (Office Only):