Good samaritan seniors clinic 2026

1. Click ‘Get Form’ to open the Good Samaritan Seniors Clinic Referral Form in the editor.
2. Begin by filling out the Patient/Applicant Information section. Enter the patient's last name, first name, initial, gender, date of birth, and Alberta Personal Health Number. Ensure all fields are completed accurately.
3. Provide the patient's address details including unit/suite, street, city/town, and postal code. Include a contact phone number and email for further communication.
4. In the Living Arrangements section, specify where the patient resides and if they require assistance at home. Indicate if an interpreter is needed.
5. Complete the Referral Information section by selecting the type of referral request and providing details about availability for short notice appointments.
6. Fill out the Mandatory Patient Information section carefully, addressing any concerns regarding memory loss or recent hospital visits.
7. Detail any medical history relevant to the patient's condition in Section D and elaborate on specific reasons for referral in Section E.
8. Once all sections are complete, review your entries for accuracy before submitting via fax or email as per submission guidelines.

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