BURNABY MATERNITY CLINIC 5th Floor, Burnaby Hospital 3935 Kincaid Street, Burnaby, B.C. V5G 2X6 Phone: 604-431-2822    Fax: 604-412-6646 Burnaby Maternity Clinic Referral Form Date of Referral: Patient Self Referral: Patient Name: Date of Birth: PHN: Address: Phone: Home Work Other Referring Physician: Billing No.: Phone: Fax: G T P A L LNMP: EDD: By Dates: By US: Certain Uncertain Obstetrical History Significant Medical Problems Please FAX the following documentation with this referral: * Prenatal Record 1 & 2 Yes No Pending * Prenatal Bloodwork (including Triple Screen) Yes No Pending Recommended labs for late referral * Ultrasound Reports Yes No Pending Additional Comments: (For Clinic Use only) Doctor: Date of Appointment: Time: Additional Comments: No Show (reason):

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