Please review the exclusion criteria before sending a referral.
Exclusion:
Age less than 18 years old
Urgent/emergent cases
Active or poorly controlled substance abuse disorders
Active or poorly controlled mood disorders
Cancer-related pain
Pain less than 3 months in duration
I have read and understood the above:
*
I agree
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Referring Physician Information
Name
*
First Name
Last Name
Billing Number
*
Are you in a FHO/FHT
Yes
No
Would you consider de-rostering your patient if they could be seen more quickly??
Yes
No
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
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Patient Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
OHIP number
*
Version Code
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Patient's medical history
Reason for referral
List current active medical conditions
List any past medical conditions
List current medications and doses
List current medications and doses
List past treatments and reason for discontinuation
List past treatments
Imaging or other relevant reports
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