Get Referral Form - Alberta Health Services

Filling out the Referral Form for Alberta Health Services is an essential process for facilitating support and services for postpartum care. This guide will provide you with clear, step-by-step instructions to ensure the form is completed accurately and efficiently.

Follow the steps to complete the Referral Form online.

1. Press the ‘Get Form’ button to obtain the Referral Form and open it in your document editor.
2. In Section A, fill in the mother's name, Alberta Health Care number, and client’s phone number.
3. Provide the infant's name, date of birth (DOB), and their Unique Lifetime Identifier (ULI) number.
4. Indicate the date the client was assessed and the infant’s age at the time of assessment in hours and minutes.
5. Select the request for either transcutaneous bilirubin (TCB) or breastfeeding support based on eligibility criteria.
6. In Section B, specify if TCB results are to be faxed to the referring physician and provide their fax number.
7. List any critical results that should be communicated directly to the physician, along with their contact number.
8. Complete the infant's birth weight, current weight, and any weight loss from birth weight, including percentage calculations.
9. Document the infant’s voiding and stooling frequency, along with any previous bilirubin results and risk factors related to feeding.
10. Finish Section B by indicating if a follow-up TCB is required and any necessary recommendations or referrals to community agencies.
11. In Section C, the public health nurse (PHN) will complete their assessment, documenting results, referrals, and PHN signature at the end.
12. Once completed, save your changes and consider downloading, printing, or sharing the form as needed.

Begin filling out the Referral Form online today to ensure timely support for postpartum services.