Physician Referral Form – click here to access form

Referral Criteria:

1. Patient has a life-limiting illness and is not planning to receive further curative treatment
2. Patient’s Palliative Performance Scale score is as follows: 40% or below for most malignant disease; 30% or below for end-stage chronic disease
3. Referring physician must seek consent from patient’s family doctor to pursue the referral
4. Home care services through the LHIN must be in place

Fax the completed referral to the Beth Donovan Hospice at (613) 258-9651. It will then be triaged accordingly.