Patient Referral Form
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Patient Name is required
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Patient's Phone Number is required and must be 10 digits
Services
(select all that applies)
Physiotherapy
Chiropractic Treatment
Nutritional Counselling
Acupuncture / Dry Needling
Psychotherapy
Occupational Therapy
Osteopathy
Personal Training
Specialized Care
(select all that applies)
Massage Therapy (lymphatic, pre/post natal, sports)
Pelvic Floor Physiotherapy
Vestibular Rehab / Concussion Management
Neurological Rehab
Products
(select all that applies)
Custom Orthotics
Bracing
TENS Unit
Compression Stockings
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Please enter Clinic/Doctor name
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Clinic/Doctor Contact Number is required and must be 10 digits
Service Location
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Please select a service location
In-Home
In-Clinic
Select Clinic Location
North York Clinic - North York Healthcare Associates (2255 Sheppard Ave E, Suite 300, North York, ON M2J 4Y1)
Scarborough Clinic - Palmdale Health Centre (3090 Kingston Rd, Suite 400, Scarborough, ON M1M 1P2)
Downtown Clinic - Bay and College Physiotherapy & Rehab (790 Bay Street, Suite 105, Toronto, ON M5G 1N8)
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Please select a clinic location
Submit