Consultation and/or Treatment Referral Form

If this is an emergency appointment, please phone our clinic at 705-326-2200

Otherwise, we will contact the patient within 24 hours upon receipt of this email form to arrange an appropriate time for consultation and/or treatment.

We require a Physician email to send your confirmation of receipt of the referral form.

NOTE TO PATIENTS:  A Physician referral is not required to obtain treatment.

Physician Info

Patient Info

Treatment Info

Is this a Motor Vehicle Accident?

Treatment Requested











Considerations/Additional Comments

Imaging Notes (X Ray, Ultrasound, MRI)