ICU Recovery Clinic Patient Self-Referral Form

If you are interested in making a self referral to the ICU Recovery Clinic program, please complete the required fields below. A member of our team will contact you within 5 business days.

You must exhibit the factors listed below for a self referral:

Admission to the ICU within the last 6 months and have ongoing physical, emotional, and/or cognitive symptoms.

PLUS any of the following diagnoses during their admission:

Mechanical ventilation for longer than 24 hours
High flow nasal cannula requirement
Acute respiratory distress syndrome
New Tracheostomy
Shock requiring vasopressor support for greater than 72 hours
Myopathy of critical illness
Delirium
Mechanical circulatory support or VV-ECMO for respiratory failure

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Phone Number

Date of Birth

Dates of ICU Stay

Dates of ICU Stay
	Dates of ICU Stay	Item weight

more items

Facility Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Facility Phone Number

Description of ongoing PICS symptoms

Pharmacy Name

Pharmacy Phone Number

List of Medications

You can also attach a medication list to the referral.

Allergies

Tobacco and Alcohol Abuse History

Primary Care Provider Contact Information

Insurance Plan Information

Company, plan, group

Insurance Plan Phone Number

Attach a copy of insurance card and medication list

Document Upload

Maximum 3 files.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

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Appointment

Doctor

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ICU Recovery Clinic Patient Self-Referral Form