Laser Centers for Health · Nanaimo, BC

Clinical & Professional Referral Form

For use by health care professionals, legal representatives, and organizations referring clients or patients for outpatient laser therapy.

Information collected on this form is used solely for intake and care coordination purposes. All submissions are encrypted and handled in accordance with BC’s Personal Information Protection Act (PIPA). Information is accessed only by authorized clinical staff for the purposes to which you have consented. Please complete this form in a private setting.

Section 1
About you — the referring professional
With the client’s written consent, we will coordinate care and provide progress updates to you directly.
Please enter your first name.
Please enter your last name.
Please enter a valid email address.
Please enter your phone number.
Please enter your organization name.
Suite / Office
Street number & name *
Please enter the street address.
City / Town *
Please enter the city.
Province *
Please select a province.
Postal code *
Please enter the postal / zip code.
Select the category that best describes your professional role, then choose your specific title.
Addiction Services▾
Mental Health Care▾
Health Care (General & Specialty)▾
Justice System▾
Social Services▾
Education▾
Workplace Support▾
Peer Support▾
Faith, Indigenous Support & Community▾
Other▾
Please select your professional role.
My general availability for scheduling
Days of the week
Preferred time windows
Select each stage at which you would like to receive a notification, with client consent. Updates follow the sequence below.
1
2
3
4
5
Section 2
About the person you are referring
This information is used for intake scheduling only. All fields are strictly confidential.
Please enter the client’s date of birth.
Please enter the client’s first name.
Please enter the client’s last name.
Please enter the client’s phone number.
Please enter a valid email address.
Optional — helps medical professionals identify the client when receiving care coordination updates
Select all that apply. Treatment programs are designed to address each client’s unique combination of needs.
Physical Addictions
Behavioural Addictions
Mental Health
Nervous System Regulation
Optional. Include any relevant background to help us prepare for the initial consultation.
Section 3
Medical pre-screening
To the best of your knowledge, please answer the following questions about the person being referred. These questions help us determine eligibility and prepare safely for the initial consultation.
In the past two weeks, has this person taken aspirin, aspirin-based products, or blood thinners?
If unsure, they can check with their pharmacist before their appointment.
In the past two years, has this person had cancer or received chemotherapy?
Does this person have a pacemaker or a defibrillator?
Is this person pregnant, or do they think they may be pregnant?
Physician clearance may be required

This is a normal part of our intake process. Based on one or more of the screening responses above, this individual may be eligible for laser therapy with written permission from their family physician or nurse practitioner.

Our clinic will review this referral and contact the client directly to discuss next steps. If physician clearance is needed, we will guide the client through obtaining it smoothly and professionally. Please do not be discouraged — this is a routine step that we manage collaboratively with the client and their primary care provider.

Optional — helps us coordinate clearance efficiently
Section 4
Consent & declaration
Both declarations below must be confirmed before this referral can be submitted.

In accordance with BC’s Personal Information Protection Act (PIPA), personal information about a third party may only be collected, used, and disclosed with that individual’s knowledge and consent. By submitting this form, you confirm that the person being referred has been informed of this referral and has consented to their information being shared with Laser Centers for Health for intake and care coordination purposes.

Declaration 1 — Your own information
I consent to Laser Centers for Health collecting and using my professional contact information for the purposes of processing this referral and coordinating care. I understand this information will be kept strictly confidential and accessed only by authorized clinical staff.
Declaration 2 — Client / patient consent
I confirm that the individual named in Section 2 has been informed of this referral and has provided their verbal or written consent to share their personal information with Laser Centers for Health for the purposes of intake scheduling and outpatient treatment. I understand that Laser Centers for Health will verify this consent directly with the client prior to beginning any treatment or sharing clinical information.
Please complete all required fields and confirm both declarations before submitting.

Referral received

Thank you for your referral. A member of our clinical team will contact the individual named within one business day to schedule their initial consultation. A confirmation has been sent to your email address.