Victory Hill Dorm Medical Information (CF4079)

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Victory Hill Dorm Medical Information (to be completed by a doctor)

The personal information collected on this form will be used for the purpose of service plan and evaluation and will be treated confidentially in compliance with the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information please contact the Director, Provincial Deaf and Hard of Hearing Services at (604) 660-1800 (voice), (604) 660-1807 (TTY), 4334 Victory St, Burnaby BC, V5J 1R2.

Child/Youth

Last Name

First Name

Medical History

Description/Concern/Diagnosis

Description/Concern/Diagnosis

Description/Concern/Diagnosis

Description/Concern/Diagnosis

Description/Concern/Diagnosis

Any other concerns not mentioned above that we should be aware of?

Current Medication

Condition

Medication

Dosage

Directions

Additional Comments e.g., possible reactions, consequences of missing medication, etc.

Allergies

Medication, food or other

Describe Reaction

Treatment

Other Professionals/Specialists Involved

Name of Doctor

Specialty

Address

City

Postal CodeUse the format A1A 1A1

Office Number

Fax Number

Alternate Number

Immunization Record

Please attach a copy of your child/youth's immunization record.

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4-6 years of age

Date of Immunization (MM/DD/YYYY)

Date of Immunization (MM/DD/YYYY)

11 year of age (Grade 6)

Date of Immunization (MM/DD/YYYY)

Date of Immunization (MM/DD/YYYY)

Date of Immunization (MM/DD/YYYY)

Date of Immunization (MM/DD/YYYY)

14 year of age (Grade 9)

Date of Immunization (MM/DD/YYYY)

Date of Immunization (MM/DD/YYYY)

Date of Immunization (MM/DD/YYYY)

Other Vaccinations

Tuberculosis Testing (Required)

Other (describe)

Date of ImmunizationMM/DD/YYYY

Signature

Doctor Name

Date Signed (MM/DD/YYYY)

Doctors's Signature

Submission

Click the PDF button to generate a printable version and submit the complete form

Mail to:

Victory Hill Dorm, c/o Patrick Tarchuk

4334 Victory Street

Burnaby BC V5J1R2

Please mark the envelope CONFIDENTIAL.

Fax To:

604-660-1859

VHD will return a copy of this form to the parent/guardian for their verification and records.

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