All patients must be referred by a physician.
(please check all that apply)
NOTE: Kindly include all the relevant reports for patient along with the referral ( ECG, bloodwork, etc )
Note: Please provide a copy of this referral form to the patient. Please advise the patients to call and fax theirrelevant clinic for immediate appointment.
Please ask patient to bring interpreter, if patient does not speak English.
Please indicate if you require additional referral forms
Note: You can also download and print the referral form from our website:
Please notify us three (3) business days prior to the appointment date, otherwise a cancellation fee will be applied