Now part of Mint Health + Drugs

Phone: (604) 770-2030 Referral fax: (604) 770-2035

Miracle PrescriptionsNorth Vancouver Call (604) 770-2030

Patient Referral Form

Print this form, complete it, and fax it to (604) 770-2035 with the patient's medication list and discharge summary if available. For urgent referrals, call (604) 770-2030.

Patient information

Patient name
Date of birth
PHN
Address
Phone
Primary contact or substitute decision maker

Referring provider

Name and role
Organization
Phone
Fax

Reason for referral (check all that apply)

  • Compliance packaging (pouch or blister) with delivery
  • Home medication monitoring and nurse visits
  • At-home medication administration (including insulin)
  • Post-surgical support or wound care
  • Opioid agonist treatment dispensing
  • Compounded preparation
  • Recent hospital discharge: medication reconciliation needed
  • Other (describe below)

Clinical summary

Attachments

  • Current medication list
  • Hospital discharge summary
  • Other

Miracle Prescriptions, 1268 Marine Drive, North Vancouver, BC V7P 1T2. Phone (604) 770-2030. Fax (604) 770-2035. Referrals are triaged within one business day; urgent post-discharge referrals are prioritized for same day or next day assessment.