Our network of trained peer support volunteers are available to visit patients in hospital who have recently undergone amputation or are facing the prospect of amputation. If you are a health care worker, patient or family member who would like to request a peer support visit please refer to this page to learn more.
If you are interested in becoming a peer support volunteer please contact us to learn more about our training program times and venues.

General

Patient's name*

MRN*       

Date of Birth (mm/dd/yy)       

Gender      Male Female 


Consent by patient for a peer visit. Patient's signature (fax only)

Consent by patient for peer visit (select for email only) Yes No 

Location of patient at time of referral

Facility name*

Facility address*

Referred by*

Profession*          

Referral phone (including area code)*

Interpreter required

             Language

Amputation type

Type/level of amputation

Above elbow Below elbow Above knee Below knee 

Other

Cause of amputation

 Congenital Vascular/diabetes Trauma/accident Tumor

Other

Date of amputation (dd/mm/yyyy)*

Additional information and/or comments

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