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      MaleFemale


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

    Consent by patient for peer visit (select for email only) YesNo

    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 elbowBelow elbowAbove kneeBelow knee

    Other

    Cause of amputation

    CongenitalVascular/diabetesTrauma/accidentTumor

    Other

    Date of amputation (dd/mm/yyyy)*

    Additional information and/or comments

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