Referral | Pro Form Sports Medicine and Rehabilitation

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PHYSICIAN REFERRAL

THIS FORM IS INTENDED FOR DIRECT REFERRALS BY PHYSICIANS. HOWEVER, A PHYSICIAN REFERRAL IS NOT REQUIRED FOR CONSULTATION AND/OR TREATMENT AT OUR CLINIC.

IF THIS IS AN EMERGENCY REFERRAL, PLEASE CONTACT US DIRECTLY AT (905) 636 - 8577.

OTHERWISE, OUR CLINIC WILL CONTACT THE PATIENT WITHIN 24 HOURS OF RECEIPT OF THIS FORM TO ARRANGE AN APPROPRIATE TIME FOR CONSULTATION AND/OR TREATMENT.

WE REQUIRE A PHYSICIAN/CLINIC EMAIL TO SEND RECEIPT OF THE REFERRAL FORM.

PHYSICIAN NAME

PHYSICIAN PHONE NUMBER

PHYSICIAN/CLINIC EMAIL

PATIENT FIRST NAME

PATIENT PHONE NUMBER

PATIENT LAST NAME

PERSONAL HEALTH NUMBER

PATIENT EMAIL

SPORTS SPECALIST CHIROPRACTIC

PHYSIOTHERAPY

REGISTERED MASSAGE THERAPY

DIETITIAN/NUTRITION COUNSELLING

CUSTOM ORTHOTICS

ORTHOPAEDIC BRACING

PRE/POST OPERATIVE REHABILITATION

CONCUSSION MANAGEMENT

COMPRESSION STOCKINGS

CLASS IV LASER

REASON FOR REFERRAL

ADDITIONAL INFORMATION CAN BE FAXED TO OUR CLINIC AT 905-636-4694

MOTOR VEHICLE ACCIDENT?

THANKS FOR SUBMITTING

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