Welcome

Interprofessional Primary Care Team (IPCT) Self-Referral Form

By providing your email you agree that GRCHC may contact you using your email for the purpose of providing information regarding specialist appointments, diagnostic testing or information related to our upcoming programs, clinics, and events at GRCHC. You understand that GRCHC cannot guarantee the security of email messages. You understand that email messages may pose a risk to your privacy. You understand at this time, messages from GRCHC will not allow for any email response from you.

Name:

Date of birth (mm/dd/yyyy)

Address

City

Postal Code

Email

Phone Number

Pronouns

They/Them

He/Him

She/Her

Family Doctor or Nurse Practitioner Name

Family Doctor or Nurse Practitioner Phone

*

Check this box if you do not have a family doctor or nurse practitioner

Please check the educational programs you would like to attend:

New Moms

Easy Fit (Gentle exercise)

Mind Body Wellness Group

Caring for my COPD

Pre-diabetes

Heart health

Please check which individual appointments you would like to attend:

I need to see a doctor or a nurse practitioner for

Well Baby appointment with a registered nurse and a nurse practitioner.

Social prescribing – Establish community connections to reduce loneliness and enhance your social wellbeing.

Mental health counselling – Develop positive coping skills for mental health challenges, such as stress, anxiety, and depression to improve your emotional wellness.

Nutrition counselling – Increase your nutrition related knowledge and set lifestyle goals for optimal health.

Please indicate if there is additional information you would like the healthcare provider to know or if you are interested in other health services:

I would like a:

In-person Appointment

Phone Appointment

Virtual Appointment