Trans Specialty Care Clinic Intake Form

*Do you live within the Vancouver Coastal Health Authority?

Includes Vancouver, Richmond, North Vancouver, West Vancouver, Sunshine Coast (Langdale, Gibsons, Sechelt, Egmont, Powell River, Pender Harbour, Madeira Park, Wilson's and Robert's Creek) and Sea to Sky Corridor (Whistler, Squamish)

	Yes
	No

Before proceeding, please ensure you have ready:

Your PHN
Your phone number
Your family doctor or nurse practitioner's address and information (if applicable)

Incomplete fields may result in problems with your self referral being added to our waitlist. If you have questions please contact our team at 604-331-8901. We are in the office from 9:00am-5:30pm Monday to Friday

Please note:Due to the high volume of incoming self-referral forms, we may not be able to respond to all completed self-referrals for patients living outside of VCH catchment, or non-eligible folks living within Fraser Health Authority. If you do not receive a response to your self-referral it may be because you are ineligible for services through our program or may have not provided enough information to contact you in the event of an incomplete referral.

If you are living within Fraser Health Authority and are over the age of 18, please contact Trans Care BC at 1-866-999-1514 or transcareteam@phsa.ca, for information on services in your area.

For more information please contact us directly at 604-331-8901 or email us at transcarintake@vch.ca.