Referral Form

PATIENT INFORMATION

Name:

OHIP:

Date of Birth:

Phone:

Address:

Email:

Patient consents to receive email/text messages

PROVIDER INFORMATION

Referring Provider:

Billing Number:

Fax/Email:

Phone:

Primary Care Provider:

REASON FOR REFERRAL

Active WSIB

Location of Pain:

Referral Pattern:

Duration of Pain:

Clinical Summary:

TYPE OF ASSESSMENT

Urgent Assessment

Reason:

First Available Pain Physician

Specific Pain Physician:

Sports Medicine

Physiatry

Comprehensive Pain Consult

Interventional Pain Referral

Specific Procedure:

Please send all relevant previous imaging for patient.
Please send relevant images with each consult.
Please provide MRI, CT, US, X-Rays if requesting infusion therapy.
Please perform baseline ECG.

Home – Referral Form

PATIENT INFORMATION

PROVIDER INFORMATION

REASON FOR REFERRAL

TYPE OF ASSESSMENT