Forms and Contact Information

Please call or forward your consult request or WRHA Palliative Care Program Application to us at the following:

Phone: 204-478-6372
Fax: 204-237-9162

Please note: staff are only available to respond to these from Monday to Friday (8:00 a.m. – 4:00 p.m.)

For Applications to the WRHA Palliative Care Program

Please complete these two forms for patients who are being referred for registration with the WRHA Palliative Care Program. Completion of the application forms does not mean patients will be registered on the WRHA Palliative Care Program. After the information on this form has been received, you will be notified in writing regarding the acceptance for registration on the WRHA Palliative Care Program.

• WRHA Palliative Care Program Application for Registration (PDF, 284 KB)
• SPICT Tool (PDF, 287 KB)
• Manitoba Palliative Care Drug Access Program Form (PDF, 28 KB)

For Consultation Services

Consultation services are generally provided during business hours, however MD to MD consults are available 24 hours, 7 days a week. Contact the MD on-call through St. Boniface paging.

Telehealth and telephone consultation support are also available to health care professionals throughout Manitoba.

Please fax your consult or call the WRHA Palliative Care Program with the patient information and your clinical question. See the above contact numbers.

• Poster: Need a Palliative Care Consult? (PDF, 386 KB)