Medical Record Request
Qualification for Hyperbaric Oxygen Therapy
Sending to
IF FAXING: 1+faxnumber@srfax.com (no dashes)
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Health Card Number
Including version code
Copies of Tests Required
Benjamin Graham
Administrative Coordinator, Patient Care & Operations
On behalf of
Please Select
Laurie-Anne Fayle, Clinic Director
Dr. Ilona Dreyzin, CPSO 63883
Dr. Vlade Gagovski, CPSO 56041
Dr. Constance Nasello, CPSO 63747
Dr. Mahmood Elahi, CPSO 64096
Dr. Meer Janjua, CPSO 96353
Derek Fayle, VP Patient Care & Operations
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