Clinician Referral Form

Freddie’s team of clinicians provide patients with affirming and evidence-driven care, without judgement. Please complete this form to submit your patient referral directly to Freddie's compassionate team.
Section A: Patient Information
Referral Program*

HIV Prevention (PrEP)HIV+ Care
First Name*
Last Name*
Preferred Name
Date of Birth*

MonthDayYear
Date
Province*
Patient's current province of residence
Phone Number*
Please enter a valid phone number.
Email Address
example@example.com
Section B: Referring Provider Information
First Name*
Last Name*
Phone*
Please enter a valid phone number.
Fax
Please enter a valid phone number.
Email
example@example.com
Which best describes you?

Primary Care ProviderSpecialist ProviderCommunity-Based OrganizationSTI clinicPubic HealthOther
Once you submit this form, Freddie will reach out to the referred patient within 72 business hours.

Note that all submissions are transmitted securely through PIPEDA/HIPAA compliant processes to ensure protection of personal health information.
Should be Empty:

Section A: Patient Information