Please fill out this short survey to refer an older adult to SSIPP chapters across Canada. 

Disclaimer: SSIPP is a friendly phone call student volunteer-based service and does not provide medical care of any sort.

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* 1. Which SSIPP chapter are you referring from? (If you are referring from a health care provider's office, enter your city.)

University of Calgary
University of Saskatchewan
University of Manitoba
University of Toronto
University of Western Ontario
University of Ottawa
Trent University

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* 2. First and Last name of Older Adult

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* 3. Phone Number of Older Adult

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* 4. Referring Health Care Provider Name

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* 5. Referring Health Care Provider Phone Number

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* 6. What is the relation of the referring provider with the older adult (physician, nurse, etc.)

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* 7. Optional: Emergency Contact Name and Number (Name, Number)

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* 8. Language Spoken (If Other than English)

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* 9. Optional: Additional Comments 

Thank you for your referral! We will do our best to match the older adult with a SSIPP volunteer as soon as possible. Please note that the older adult may be matched with a volunteer from another chapter. 

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