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
Service(s) Required (select all that applies)
Please select atleast one service
Physiotherapy
Acupuncture
Chiropractic Treatment
Massage Therapy
Custom Made Orthotics
Nutritional Counselling
Bracing (Custom)
Bracing (OTS)
Speech Language Pathology
Compression Stockings (15-20 mmhg)
Compression Stockings (20-30 mmhg)
Compression Stockings (30-40 mmhg)
Occupational Therapy
Personal Training
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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