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The BC Women's Centre for Reproductive Health
at BC Women's Hospital and Health Sciences Centre

D-600- 4500 Oak Street Street
Vancouver, BC 
Canada, V6H 3N1
T: 604-875-2445 F: 604-875-2524

How to make an appointment
Sections 1, 2 and 3 of this form may be filled in and given to your doctor who may complete the form and make a referral by faxing it to us at: (604) 875-2524. You can use the "Print" button at the bottom of this form, or just use the "Print" button in your browser .
We will contact the patient directly with appointment time.
 Section 1
PATIENT’S FIRST NAME:
SURNAME:
DATE OF BIRTH:

AGE:
CARE CARD#:
 Section 2
PARTNER’S FIRST NAME:
SURNAME:
DATE OF BIRTH:
AGE:
CARE CARD#:
ADDRESS:
CITY:
PROVINCE:
POSTAL:
TELEPHONE: HOME:
PATIENT WORK:
PARTNER WORK:
 Section 3
REFERRING PHYSICIAN:
 
  OB/GYN GP
BILLING #:
ADDRESS:
CITY:
PROVINCE:
POSTAL:
If this referral is to a specific clinic physician, please indicate here:
Dr.
   
(if left blank, an appointment will be arranged)
Has the patient been here before?
Yes No
Do they speak and understand English?
Yes No
If No, please have patient bring an interpreter to their appointment or hospital interpreters available at $40/hr
How long have they been trying to conceive with their current partner?
SERVICE REQUESTED: Please note that previous infertility testing is not required prior to a patient being seen at the clinic. Please indicate whether the referral is for an initial infertility work-up and/or for a specific type of treatment.
Initial Fertility Workup Endocrine Assessment
Intrauterine insemination (IUI) (anonymous donor spem)  Endometriosis/Pelvic Pain
Intrauterine Insemination (IUI) )partner’s sperm) Male Factor Infertility
In Vitro Fertilization (Age 43 or younger) Menopause
Tubal Ligation Reversal ( Age 40 or younger)  
Other:
MEDICAL RECORDS: If a previous work-up has been done, please append copies of relevant information.
Female Partner:
Hysterosalpingogram
  Operation Reports (eg. laparoscopy, hysteroscopy)
  Consultation reports
Lab Reports (eg. hormonal assays, rubella)
Male Partner:
Semen analysis
  Urological Consultation Reports
 
 

 

 

 

 

Fertility Services
In Vitro Fertilization (IVF)
Male Infertility
Sperm Banking
Endometriosis & Pelvic Pain
Reproductive Surgeries
Abnormal Periods
Polycystic Ovarian Syndrome (PCOS)
Menopause