• Patient Contact Information

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  • Please note: Non-medical services/clinicians are not covered by OHIP, but may be covered by private insurance plans.

  • Reason for Referral (indicate all that apply):

  • Physician Information

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  • I acknowledge that I am actively involved in the care of this patient and can act on the recommendations made by The Possibilities Clinic.

  • Once your referral has been processed, you will receive a fax confirming receipt.

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