Dr Bazza Function-Focused Stabilization Program

Safety. Function. Stabilization. Shared Care.

Physician Referral Form | Referral-Based | Time-Limited Stabilization | Shared Care

Referral destinationDr Bazza, MD, CCFP - Family Physician (Focused Practice)
Consultation and stabilization in complex care: mental health, addiction, chronic pain, and medication complexity.

Referral Transmission

Clinic / Program fax

Date sent

Referring clinician / clinic

Referral contact phone / fax

1. Patient Information

Patient name

PHN / ULI

DOB

Patient phone

Current pharmacy

Current primary prescriber

2. Reason for Referral

Opioid complexity Benzodiazepine / Z-drug OAT / addiction Chronic pain / fibromyalgia Mental health complexity Functional / somatic disorder Polypharmacy / co-sedation Disability function support Other

Specific referral question / requested assistance

3. Requested Service Type

4. Key Risk Concerns

Brief clinical summary and risk context

5. Current Medication Information

Current medications relevant to referral (or attach medication list)

Last opioid/benzo/z-drug prescription date, if relevant

Current dispense pattern, if known

6. Function-Focused Referral Information

What is the patient unable to do now that they want to be able to do?

Work/productivity impaired ADLs impaired Sleep impaired Physical function impaired Social/relationship function impaired Disability forms/support needed

7. Relevant History / Investigations

Pertinent diagnoses, previous treatments, investigations, or barriers to care

8. Attachments Requested

9. Urgency / Safety

Routine Semi-urgent High safety concern - specify below

Urgency explanation / immediate safety concerns

10. Referral Acknowledgement

I understand this is a consultation and time-limited stabilization service. Referral does not imply automatic prescribing takeover, automatic continuation of controlled medications, or replacement of ongoing primary care. Urgent or emergent concerns should be directed to ED/urgent services.

Referring clinician signature

Date

Download referral forms

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Fax completed referrals to 825-600-5926 or email referral inquiries to referrals@dbfsp.ca. Confirm privacy/security workflow before accepting patient-identifiable information by email.