Health Care Providers Form

To be completed by a licensed General Practitioner, Specialist, Nurse Practitioner, or Clinician registered in British Columbia.

This form is Step 2 of the VFFLS client-member application. It must be completed independently by the referring healthcare provider. The patient should NOT complete this form on their provider's behalf.

Fields marked * are required.

Referrring Health Care Provider

First name

Last name

Professional Title

College Registration Number

Email Address

Phone Number

Clinic or Hospital Name

Patient Information

Patient First Name

Patient Last Name

Patient Date of Birth

Year

Month

Day

How Long Have You Been Their Provider?

Confirmed Diagnosis *

HIV

Hepatitis C

Cancer

Other Life-Challenging Illnesses

Additional Clinical Notes (Optional)

Clinical Recommendation

In your clinical opinion, do you support this patient's application to VFFLS?

Yes, I support this application

Yes, with conditions (refer notes below)

I do not support this application at this time (please provide context if comfortable)

Recommended wellness programs (select all appropriate)

Acupuncture

Lunches

Counselling

Massage Therapy

Reflexology

Naturopathic

Yoga

Reiki

Art Therapy

Workshops

Seminars

Other

Any programs you would advise against, or additional notes for VFFLS staff?

Professional Certification

By submitting this form, you are providing a professional attestation on behalf of your patient. Please read carefully before submitting.

I certify that I am a licensed healthcare provider registered in the Province of British Columbia, and that the patient named above is living with a life-altering illness as indicated.

I acknowledge that VFFLS offers complementary wellness services. The choice of modalities is ultimately the patient's. This form does not create a liability for VFFLS or myself regarding those choices.

Step 2 - Your Doctor

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